Final Flashcards
1
Q
1) What are the two components of the sensory process? A) Stimulus and receptor B) Kinesthesia and stereognosis C) Visual and auditory D) Reception and perception
A
Answer: D
Explanation: A) The sensory process involves two components: reception and perception. Sensory reception is the process of receiving stimuli or data. Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information. Stimuli and receptors are aspects of how sensory information is received and perceived. Kinesthesia is awareness of the position and movement of body parts, and stereognosis is the ability to perceive and understand an object through touch. Visual and auditory stimuli are parts of how the body senses the external world.
2
Q
2) The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory deficits?
A) Adequate room lighting with night lights
B) Flashing alarm clock with large numbers
C) Amplified telephone
D) Large-print reading material
A
Answer: B
Explanation: A) A flashing alarm clock would be helpful for a client with a hearing deficit, and a clock with large numbers would be helpful for a client with a sight deficit. Adequate room lighting with night lights and large-print reading material help with a sight deficit but not a hearing deficit, and an amplified telephone helps with a hearing deficit but not a sight deficit.
3
Q
3) The nurse is planning care for an older adult client diagnosed with age-related macular degeneration (AMD) that is nonexudative. Which therapies should the nurse anticipate for this client? Select all that apply. A) Laser surgery B) Eye patches C) Antioxidants D) Eyedrops E) Zinc
A
Answer: C, E
Explanation: A) High-dose antioxidants and zinc are the treatments of choice for early-to-intermediate dry AMD. Laser surgery is used to treat wet macular degeneration. Eyedrops and eye patches may be used after laser surgery but are not part of the initial treatment for the disorder.
4
Q
4) A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this client? A) Rosenbaum eye chart B) Penlight C) Cover-uncover test D) Snellen eye chart
A
Answer: A
Explanation: A) The Rosenbaum eye chart is used to test for near or reading vision. The Snellen chart is used to test far or distant vision. A penlight is used to test extraocular movements and pupillary response. The cover-uncover test is used to assess for eye muscle strength.
5
Q
5) Which diagnostic test should the nurse use to assess hearing in an infant? A) Otoacoustic emissions test B) Weber test C) Rinne test D) Whisper test
A
Answer: A
Explanation: A) The otoacoustic emissions test uses an earphone and microphone to play sounds into the ear. Failure to detect an echo indicates hearing loss. This test is almost exclusively performed on infants as part of the routine hearing screening. The Rinne and Weber tests assess bone and air conduction with the use of a tuning fork. The whisper test provides a rough estimate of hearing loss. All three of these other tests involve active participation from the client.
6
Q
6) The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this teaching?
A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months.
B) Annual screenings are recommended for adults with diabetes.
C) For individuals without comorbidities, hearing exams should be repeated every 1-3 years for ages 55-64, and every 1-2 years for ages 65 and above.
D) Have a hearing test every 10 years until age 50 and then every 3 years.
A
Answer: D
Explanation: A) Adults should be screened for hearing at least every 10 years until the age of 50 and then every 3 years. A biannual or annual hearing test is not necessary for this age group. Annual screenings for vision are recommended for adults with diabetes, and for individuals without comorbidities, eye exams should be repeated every 1-3 years for ages 55-64, and every 1- years for ages 65 and above.
7
Q
7) The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn child? A) Lack of immunity to rubella B) History of otitis media C) Immunity to varicella D) Brief case of moderate conjunctivitis
A
Explanation: A) Maternal infection with rubella during pregnancy can cause vision impairment in newborns. Thus, lack of immunity to rubella indicates an increased risk of sensory impairment in the newborn. Immunity to varicella is a desirable trait that reduces a mother’s chance of illness during pregnancy, thus lessening the likelihood of harm to the newborn. Sensory deficits resulting from maternal otitis media would not be hereditary. Conjunctivitis, or pink eye, is an infection that usually clears up on its own and is not congenital.
8
Q
8) A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this client’s visual sensory overload?
A) Suggest the client wear sunglasses that block UVA rays only.
B) Reduce the amount of light in the room by lowering shades and turning off overhead lights.
C) Provide the client with large-print reading materials.
D) Encourage the patient to employ relaxation techniques to reduce anxiety and stress.
A
Answer: B
Explanation: A) For clients who are at risk of overstimulation, nurses should assist with reducing the number and types of environmental stimuli. Appropriate measures for addressing visual overstimulation include lowering the shades and turning off overhead lights. Dark glasses that block both UVA and UVB rays are also useful. Relaxation techniques would be good for the client to employ but would require teaching for the client to properly implement them. Large-print reading materials would be helpful for a client with visual impairment but not a client who is experiencing visual sensory overload.
9
Q
9) A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial nerve? A) XII B) XI C) VIII D) VI
A
Answer: A
Explanation: A) The movement of the tongue for speech and swallowing is controlled by cranial nerve (CN) XII, hypoglossal. XI CN (accessory) controls the movement of head and neck as well as proprioception. CN VIII (acoustic/vestibulocochlear) controls hearing and the sense of balance. CN VI (abducens) control eyeball movement and moves eye laterally.
10
Q
10) Which nursing action is most appropriate when communicating with a client who has a hearing deficit?
A) Drawing out the articulation of words with extra emphasis in order for the client to understand
B) Using shorter phrases, which tend to be easier to understand than longer ones
C) Varying the volume of voice, which is easier to understand than one consistent volume
D) Writing ideas or pantomiming as appropriate in order for the client to understand
A
Answer: D
Explanation: A) Writing ideas and pantomiming as appropriate are acceptable forms of communication for a client who has a hearing deficit. The nurse should not overarticulate words, use short phrases, or vary the volume of voice because these things make it more difficult to understand for the client with a hearing deficit.
11
Q
11) What is vertigo? A) Involuntary rapid eye movements B) A feeling of rotation or imbalance C) An infection of the vestibular nerve D) Impaired olfaction
A
Answer: B
Explanation: A) Vertigo is a feeling of rotation or imbalance. Nystagmus is involuntary rapid eye movements. Vestibular neuritis is an infection of the vestibular nerve that is a common cause of vertigo. Impaired olfaction, or impaired sense of smell, has nothing to do with vertigo
12
Q
12) Where does perception, or the awareness and interpretation of stimuli, take place? A) The brain B) The nerve receptors C) The peripheral nervous system D) The impulses
A
Answer: A
Explanation: A) Perception, or awareness and interpretation of stimuli, takes place in the brain. The nerve receptors convert stimuli to impulses that travel along nerve pathways to the spinal cord or directly to the brain.
13
Q
13) What characterizes individuals with achromatopsia?
A) They perceive only the secondary colors of purple, orange, and green.
B) They perceive only the primary colors of red, blue, and yellow.
C) They perceive some colors as indistinguishable from other colors.
D) They perceive only shades of gray and no colors.
A
Answer: D
Explanation: A) Achromatopsia is a rare form of color blindness in which the individual cannot distinguish any color at all and sees only shades of gray. The most common variant of color blindness is the inability to distinguish between red and green. Less common is the inability to distinguish between blue and yellow. Many people with the blue-yellow variant also have problems distinguishing between green and red.
14
Q
The nurse suspects that an older adult client has a hearing disorder; however, the client denies not being able to hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the client’s hearing is appropriate?
A) Use an otoscope to visualize the inner ear.
B) Schedule a Weber and Rinne test.
C) Confront the client with the suspicion.
D) Observe the client’s interaction with family
A
Answer: D
Explanation: A) The most telling of these options would be to observe the client’s interactions with family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip reading. The Weber and Rinne test and use of an otoscope may be a part of an assessment but will not yield the immediate information that simple observation would. The client has already denied having a hearing problem, so confronting the client with the nurse’s suspicion will probably only alienate the client from the nurse.
15
Q
A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his hearing?
A) “If my hearing is damaged on the job, I can have surgery to fix it.”
B) “Hearing loss from exposure to loud noises actually has a genetic component.”
C) “Damage to the ear from loud noises can cause permanent hearing loss.”
D) “Hearing loss attributed to loud noises is normally reversible, especially in younger people.”
A
Answer: C
Explanation: A) Hearing loss attributed to loud noises can be profound and is often permanent, regardless of a person’s age. With sensorineural hearing loss, the only hope for restoring sound perception might be a cochlear implant; however, this surgery is not appropriate for all cases of sensorineural hearing loss, and even if a client is an ideal candidate, implants aren’t always successful. Hearing loss from loud noises has no genetic component.
16
Q
) Which is the decibel level for mild hearing loss? A) 16-40 dB B) 41-70 dB C) 71-90 dB D) 91+ dB
A
Answer: A
Explanation: A) Hearing loss is expressed in terms of decibels, or units of loudness. 41-70 dB is moderate hearing loss, at which most normal conversational sounds are missed. 16-40 dB is mild hearing loss, at which some speech sounds are difficult to perceive. 71-90 dB is severe hearing loss, at which speech sounds cannot be heard at a normal conversational level. 91+ dB is profound hearing loss and constitutes legal deafness.
17
Q
The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this client? A) Impaired Verbal Communication B) Social Isolation C) Nausea D) Risk for Injury
A
Answer: C
Explanation: A) Possible nursing diagnoses for the patient with hearing impairment may include Impaired Verbal Communication, Social Isolation, and Risk for Injury. Nausea is accurate for a client who has tinnitus, vertigo, and nausea; however, the greater priorities for this client would be safety related to falls, ensuring effective communication, and ensuring that the client does not become socially isolated.
18
Q
Which client should the nurse identify as having the greatest risk for hearing loss?
A) Construction worker who typically works in urban centers
B) Adolescent who occasionally listens to loud music on headphones
C) Teacher who works at a large high school
D) Lawyer who enjoys snowmobiling once a year
A
Answer: A
Explanation: A) The construction worker is likely to have the greatest risk for hearing loss because the client’s occupation and typical work environment probably involve sustained exposure to very loud noises. An adolescent who occasionally listens to loud music on headphones is also at risk for hearing loss, but the exposure to loud sounds is only occasional. The teacher working at a large high school works in a noisy environment but is probably not typically exposed to sounds louder than the human voice. Snowmobiles can be loud enough to present a risk for hearing loss, but the lawyer’s exposure to them is only once a year.
19
Q
A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social isolation?
A) “I ask others to face me when they talk because I can hear them better.”
B) “I keep the television volume raised to a high level.”
C) “I don’t use my hearing aid unless someone seems to need to talk to me.”
D) “I might use the hearing aid when I go shopping.”
A
Answer: A
Explanation: A) Evidence that the client is effectively addressing variables that may lead to social isolation would include the client’s account of asking others to face him or her when talking. This indicates that the client is taking an active role in improving communication with others. Clients should be encouraged to interact with friends and family on a one-to-one basis in quiet settings. Listening to a loud television at all times is not conducive to good communication. The other responses indicate a reluctance to use an assistive device unless necessary, which does not generally encourage social interaction.
20
Q
Which strategy for communication enhancement incorporates the use of shapes? A) Sign language B) Oral approach C) Total communication D) Cued speech
A
Answer: d
Explanation: A) Of the strategies listed, only cued speech incorporates the use of shapes. Specifically, cued speech accompanies oral speech with hand shapes that represent groups of consonant sounds. Both sign language and total communication use signs, not shapes. An oral approach involves only spoken communication and avoids the use of formal signs.
21
Q
) A school nurse is identifying students who may have hearing loss. Which student would the nurse be most concerned about?
A) A child who startles easily at loud noises
B) A child who gets annoyed when things like televisions are too loud
C) A child who cannot follow conversations in the hallways between classes or in the cafeteria
D) A child who likes to listen to music on earbuds
A
Answer: C
Explanation: A) The child who cannot follow conversations in the hallways between classes or in the cafeteria appears to be having trouble understanding speech when background noise is present, which is a sign that the child may require further evaluation for hearing loss. A child not startling at loud noises would be a sign of hearing loss. A child who gets annoyed when electronic devices are too loud or who likes to listen to music on earbuds is behaving normally
22
Q
A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to do?
A) Understand the actions and drug interactions of aminoglycosides.
B) Self-monitor for hearing loss.
C) Use total communication.
D) Understand cued speech.
A
Answer: B Explanation: A) Tobramycin, an aminoglycoside antibiotic, is used in the treatment of advanced bacterial infections and for the treatment of tuberculosis. A potential serious adverse effect of this class of medication is ototoxicity, affecting the client's hearing. The nurse should plan on teaching the client how to self-monitor for hearing loss. Total communication and cued speech are approaches to enhancing communication with clients who have a hearing deficit. It is not important for the client to understand the actions and drug interactions of the group of drugs to which tobramycin belongs.
23
Q
A nurse is working with several clients who are experiencing hearing loss. Of these clients, which is the best candidate for a cochlear implant?
A) A client with a perforated tympanic membrane
B) A client with sensorineural hearing loss from long-term exposure to loud noise
C) A client with an obstruction of the external ear canal
D) A client with a tumor of the middle ear
A
Answer: B
Explanation: A) For the client with a sensorineural hearing loss, a cochlear implant may be the only hope for restoring sound perception. Clients with a perforated tympanic membrane, an obstruction of the external ear canal, or a tumor of the middle ear all have problems that lead to conductive hearing loss, which would not be treated with a cochlear implant.
24
Q
What is characteristic of conductive hearing loss?
A) For loss of hearing to be the same at all frequencies
B) For loss of hearing to primarily involve the upper frequencies
C) For loss of hearing to primarily involve the middle frequencies
D) For loss of hearing to primarily involve the lower frequencies
A
Answer: A
Explanation: A) Conductive hearing loss involves an equal loss of hearing at all frequencies. If the level of sound is greater than the threshold for hearing, speech discrimination is good. Because of this, the patient with a conductive hearing loss benefits from amplification by a hearing aid. Sensorineural hearing loss typically affects the ability to hear high-frequency tones
25
What is conductive hearing loss?
A) Degeneration of the hair cells of the cochlea
B) Damage to the hair cells of the organ of Corti
C) Disruption of the transmission of sound from the external auditory meatus to the inner ear
D) Decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli
Answer: C
Explanation: A) Conductive hearing loss is any disruption of the transmission of sound from the external auditory meatus to the inner ear. Sensorineural hearing loss is a decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli. Damage to the hair cells of the organ of Corti is a significant cause of sensorineural hearing deficit. Degeneration of the hair cells of the cochlea is involved in progressive sensorineural hearing loss with aging, called presbycusis.
26
Which of the following best describes tinnitus?
A) A ringing sound accompanying perception of high-frequency tones
B) Auditory perception from visual stimuli
C) Lack of auditory perception of external auditory stimuli
D) Auditory perception without external auditory stimuli
Answer: D
Explanation: A) Tinnitus is the perception of sound or noise in the ears without stimulus from the environment. The sound may be steady, intermittent, or pulsatile and is often described as a buzzing, roaring, or ringing. It would not be ringing accompanying the perception of high-frequency tones because such a perception would involve external auditory stimuli. Lack of auditory perception of external auditory stimuli is lack of hearing. Tinnitus does not involve perception of visual stimuli as auditory.
27
After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate?
A) "Only your doctor can tell if you have a cataract in your left eye."
B) "Cataracts develop at different rates, so one eye may be more affected than the other."
C) "The changes being confined to one eye indicate a less severe cataract."
D) "Surgery is still necessary for both eyes."
Answer: B
Explanation: A) The nurse should respond that cataracts tend to occur in both eyes and develop at different rates, and one cataract generally matures more rapidly than the other. The nurse should not tell the client that the healthcare provider is the only one who can tell if the client has a cataract in the left eye. The lack of vision changes in the left eye does not necessarily indicate the severity of the condition, and surgery might not be necessary for either eye.
28
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Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts?
A) Age 75 years
B) Hypertension
C) Moderate alcohol use
D) Smoker
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Answer: A
Explanation: A) Age is the greatest single risk factor for cataracts. Environmental and lifestyle factors, such as long-term exposure to sunlight, increase the risk for cataracts; cigarette smoking and heavy alcohol consumption are associated with earlier cataract development. This client's age would indicate a predisposition for cataract formation, but not hypertension or only moderate alcohol use. Being a smoker would indicate such a predisposition, but this is still not as great a risk factor as the client's age.
29
) A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract?
A) Two-month-old infant who is asymptomatic
B) Six-month-old infant with difficulty noticing toys or faces
C) Three-month-old infant with diminished reaction to bright light
D) One-month-old infant with no reaction to bright light and failure to notice toys or faces
Answer: D
Explanation: A) If vision impairment is significant, the infant should undergo surgical removal of the cataract within the first 2 months of life. For children older than 2 months, cataract surgery should be performed at the discretion of the healthcare provider. The asymptomatic 2-month-old infant is not displaying signs of significant vision impairment, but the 1-month-old infant is.
30
An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client?
A) Disturbed Body Image
B) Decisional Conflict: Cataract removal
C) Risk for Ineffective Health Maintenance
D) Ineffective Coping
Answer: C
Explanation: A) The client has arthritis, which is a chronic condition and may interfere with the client's ability to manage self-care and postoperative care after cataract removal. Risk for Ineffective Health Maintenance is the diagnosis with the highest priority for the client at this time. There is no evidence to suggest the client is not coping or is experiencing decisional conflict regarding the removal of the cataracts. The client might have a disturbed body image; however, postoperative care is the highest priority at this time.
31
The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery?
A) Ensuring fall hazards are removed from the client's home and additional lighting is provided
B) Educating the client about what self-care activities are necessary following surgery
C) Making the client's close family aware of the self-care instructions the client has received
D) Ensuring the client's employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider
Answer: A
Explanation: A) The removal of fall hazards from the client's home and provision of additional lighting best demonstrates providing a safe environment for the client following surgery. It's important for the client to understand what self-care activities are necessary, and it's good that the client's close family members are aware of the self-care instructions the client has received and that the client's employer doesn't expect an immediate return to standard duties, but these don't relate directly to providing a safe environment
32
Which diagnostic technique is used to confirm the location and extent of cataracts?
A) Visually inspecting the optic fundus using an ophthalmoscope
B) Using tonometry to indirectly measure intraocular pressure
C) Revealing a dark area instead of the red reflex through ophthalmoscopy
D) Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract
Answer: D
Explanation: A) Cataracts are diagnosed on the basis of the patient's history and eye examination. The Snellen and Rosenbaum charts are used. A dilated eye exam with either an ophthalmoscope or slit-lamp examination provides a magnified view of the structures of the eye. Ophthalmoscope examination confirms the diagnosis by identifying the location and extent of a cataract. Revealing a dark area is something that would happen only as the cataract matures. Visually inspecting the optic fundus and using tonometry to measure intraocular pressure are diagnostic tests for glaucoma.
33
A client has been diagnosed with cataracts of both eyes. The client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client?
A) Corrective lenses for the cataracts
B) Two surgical procedures, separated by a few weeks, to remove the cataracts
C) Two surgical procedures to remove both cataracts at the same time
D) Eyedrops to treat the cataracts
Answer: B
Explanation: A) Surgery is the only treatment for cataracts. The client will have one cataract removed, and then, in a few weeks, the other cataract will be removed. Cataracts cannot be treated with eyedrops or corrective lenses.
34
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A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts?
A) Congenital
B) Secondary
C) Radiation
D) Traumatic
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Answer: B
Explanation: A) A secondary cataract may form following surgery to correct another eye disorder. Congenital cataracts are hereditary and appear at birth or in early childhood. Traumatic cataracts result from injury to the eye, and radiation cataracts result from long-term exposure to radiation.
35
Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client?
A) A diagram showing a completely closed anterior chamber angle
B) A diagram showing a completely occluded outflow of aqueous humor
C) A diagram showing a blockage of the trabecular meshwork and canal of Schlemm
D) A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm
Answer: D
Explanation: A) The diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm demonstrates open-angle glaucoma. In open-angle glaucoma, the anterior chamber angle would be normal but outflow of aqueous humor would be reduced, although not to the degree that it was completely prevented, causing a rising intraocular pressure.
36
Which assessment finding is consistent with a diagnosis of open-angle glaucoma?
A) A client loses vision intermittently several times over the course of several hours.
B) A client has an episode of lost vision when experiencing a panic attack.
C) A client loses the ability to see at all during a city-wide blackout.
D) A client experiences gradually diminishing vision in both eyes over an extended period.
Answer: D
Explanation: A) Open-angle glaucoma tends to be a chronic and gradually progressive disease. It typically affects both eyes, although the pressures and progression may not be symmetric. Patients with angle-closure glaucoma may have intermittent episodes lasting several hours before they have a more typical prolonged attack of angle-closure glaucoma. Because of the effect of pupil dilation on aqueous outflow in angle-closure glaucoma, episodes often occur in association with darkness, emotional upset, or other factors that cause the pupil to dilate.
37
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An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply.
A) Blurred vision
B) Intermittent loss of eyesight
C) Headaches
D) Clouding of the eyes
E) Change in eye color
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Answer: A, E
Explanation: A) The client is taking a prostaglandin analog as eyedrops, which can cause the side effect of a change in iris color. Other potential side effects are blurred vision, eye pain (itching, burning, stinging), and eye redness, but not intermittent eyesight loss, headaches, or clouding of the eyes.
38
The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need?
A) Assure the client there is nothing to be afraid of.
B) Support the client's use of coping mechanisms.
C) Turn off the lights when leaving the client's room.
D) Refer the client to a counseling psychologist.
Answer: B
Explanation: A) Anxiety is a common response to a new diagnosis of glaucoma. Here, the most appropriate intervention would be for the nurse to support the client's use of coping mechanisms. Although referral to a psychologist may be necessary at some point, it typically is not an initial course of action. Assuring the client there is nothing to be afraid of minimizes the client's concerns and is not appropriate. Turning off the lights is not an intervention that will lessen the client's anxiety.
39
The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective?
A) "The eyedrops only need to be used when my eyes hurt."
B) "I can stop the eyedrops when the glaucoma has resolved."
C) "I must use my eyedrops as prescribed for the rest of my life."
D) "I will need to continually increase the dose of my eyedrops."
Answer: C
Explanation: A) Glaucoma can be controlled but not cured; the client must use eyedrops for the rest of his life. Eyedrops must be used continuously as prescribed; most clients with glaucoma do not experience eye pain. Increasing the dosage of eyedrops is only necessary if the ocular pressure is not controlled; this must be determined by the healthcare provider, not the client.
40
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The nurse is caring for a client who has been using timolol (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug?
A) Eye pain
B) Heart rate of 57
C) Urinary frequency
D) Blurred vision
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Answer: B
Explanation: A) The onset of bradycardia must be evaluated. Timoptic is a beta-adrenergic blocker. It is associated with bradycardia in some clients. Frequent urination is associated with the use of carbonic anhydrase inhibitors. Eye pain and dim or blurred vision are associated with the use of miotic medications.
41
The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching? Select all that apply.
A) Manage eye pain with over-the-counter analgesics.
B) Clouding of the affected eye(s) is expected.
C) Self-administer prescribed eye medication properly.
D) Attend follow-up appointments with the physician.
E) Avoid over-the-counter medication unless discussed with the physician.
Answer: C, D, E
Explanation: A) When instructing a client on how to manage the diagnosis of glaucoma, the nurse should include why the client needs to avoid over-the-counter medication unless discussed with the physician, the method to self-administer prescribed eye medication, and the importance of attending follow-up appointments with the physician. Eye pain or clouding of affected eyes is not to be expected and should be reported to the physician.
42
Which of the following scenarios is consistent with secondary congenital glaucoma?
A) A newborn is diagnosed with glaucoma at birth.
B) An infant is diagnosed at 6 months with glaucoma.
C) A 1-year-old infant develops glaucoma following neurofibromatosis.
D) A 5-year-old child is diagnosed with glaucoma
Answer: C
Explanation: A) Secondary congenital glaucoma results from disorders of the eye or the body, including Sturge-Weber syndrome, Axenfeld-Rieger syndrome, aniridia, and neurofibromatosis, so the 1-year-old infant who develops glaucoma following neurofibromatosis has secondary congenital glaucoma. The newborn diagnosed at birth with glaucoma has congenital glaucoma, the infant diagnosed at 6 months has infantile glaucoma, and the child diagnosed at 5 years has juvenile glaucoma.
43
A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include?
A) "This drug reduces pressure in the eye by relaxing the muscles of the eye."
B) "This medication only needs to be taken when eye pain is experienced."
C) "Systemic absorption may occur, resulting in hypotension, bradycardia, and shortness of breath."
D) "This drug reduces intraocular pressure by decreasing the production of fluid in the
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Answer: D
Explanation: A) Ophthalmic beta-adrenergic blocking agents are one type of pharmacologic therapy used in the treatment of glaucoma. This class of medication works to reduce intraocular pressure by decreasing the production of aqueous humor in the ciliary body. Systemic absorption is a potential side effect of this type of drug, not the therapeutic action of the drug. This type of drug should be taken once or twice a day, not on as-needed basis when pain occurs. Relaxation of the ciliary muscle is an effect of prostaglandin analog drugs, another class of medications used in the treatment of glaucoma.
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44
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An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing?
A) Cataract
B) Detached retina
C) Exudative macular degeneration
D) Nonexudative macular degeneration
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Answer: D
Explanation: A) Symptoms of age-related macular degeneration usually develop gradually and include needing more light to read, blurriness of print, or a blurred or blind spot in the central vision. The macular degeneration is likely nonexudative (dry) because that is the more common kind and it develops before the exudative (wet) type. Cloudy vision is seen with cataracts. When the retina detaches, the client experiences floaters, or spots, and lines or flashes of light in the visual field.
45
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The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration?
A) Caucasian ancestry
B) Smoking 1 pack of cigarettes per day
C) 62 years of age
D) Family history of AMD
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Answer: B
Explanation: A) Although aging is the most significant risk factor for the development of macular degeneration, and being Caucasian and having a family history of AMD are also risk factors, of the options listed, only smoking is modifiable, meaning that it is a risk factor the client can control.
46
An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority?
A) Talk with the client to assess for other hallucinations that might be occurring.
B) Check the client's medications for side effects of vision changes.
C) Ensure the client's safety by raising the bedrails.
D) Contact the healthcare provider for an immediate ophthalmologic evaluation.
Answer: D
Explanation: A) Individuals with dry intermediate macular degeneration can progress to exudative macular degeneration. A sudden distortion in vision and impaired color vision are signs of exudative macular degeneration and require prompt evaluation and treatment. Thus, the nurse needs to contact the healthcare provider so that the client can be seen by an ophthalmologist. The client most likely is not experiencing a side effect of medications. Ensuring the client's safety is important; however, the nurse needs to do more than raising the bedrails. The client is not hallucinating, although hallucinations are a sign of exudative macular degeneration as well.
47
Which of the following clients most likely will require assistance with properly taking medications for macular degeneration?
A) 72-year-old client, no dementia, no arthritis, hypertension
B) 67-year-old client, dementia, arthritis, no hypertension
C) 47-year-old client, no comorbidities
D) 52-year-old client, gastroesophageal reflux disease (GERD), hypertension
Answer: B
Explanation: A) Two common conditions in older adults that may affect treatment of macular degeneration are tremors and cognitive decline. Hand tremors may make it difficult for the older adult to adequately apply eyedrops, and cognitive decline may cause older adults to forget to take their medications. Therefore, older adults with these conditions may need a family member or friend who can help them remember to take their medications and potentially apply eyedrops for them. The client with dementia and arthritis, although not the oldest of these clients, has conditions that are most likely to make taking medications properly difficult.
48
The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD) and type 1 diabetes mellitus. What should the nurse include in this client's teaching plan?
A) Information on assisted-living facilities
B) Information on the need to have routine eye examinations every 5 years
C) Referral to home care to ensure safety with administering insulin and AMD medications at home
D) Information on Stargardt disease
Answer: C
Explanation: A) The client has macular degeneration and type 1 diabetes, which means the client needs insulin at least once per day. The nurse should refer the client for home care to ensure that the client can safely provide insulin at home as well as assist with other medications the client might need for management of AMD. The client may or may not need to move to an assisted-living facility. Stargardt disease is the most common type of juvenile macular degeneration and not likely relevant to this client. Routine eye examinations for this client should be done every 2 years.
49
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The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease?
A) High-antioxidant diet
B) Low-antioxidant diet
C) Low-fat diet
D) High-fat diet
```
Answer: A
Explanation: A) A diet high in antioxidants–such as fish; green, leafy vegetables; copper; and zinc–has been shown to slow the progression of macular degeneration in its early to intermediate stage when it is nonexudative. Neither low- nor high-fat diets slow the progression of macular degeneration.
50
A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate?
A) It will increase the effectiveness of surgery.
B) It will reverse the effects on the disease.
C) It will promote the development of new blood vessels.
D) The progression of the disease will be slowed.
Answer: D
Explanation: A) One treatment for macular degeneration is the use of verteporfin, a drug that tends to adhere to the surface of new blood vessels. This medication is injected systemically. Light is then shined into the affected eye, activating the drug and destroying new blood vessels. The best outcome for this treatment is that it will slow the disease. This does not reverse the symptoms of the disease. New vessel growth is not desirable. The client's condition will be slowed at best; it is not likely to improve. Surgical therapy is rare as a treatment for AMD and this medication does not improve the efficacy of surgery.
51
The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client? Seslect all that apply.
A) Keep the stairs free of clutter.
B) Wear socks without shoes when walking in the home.
C) Use one electrical outlet for devices.
D) Have grab bars installed in the bathroom.
E) Remove scatter rugs from the floors in the home.
Answer: A, D, E
Explanation: A) The client with macular degeneration is at risk for injury. To reduce this risk, the nurse should instruct and plan to help the client remove scatter rugs from the floors in the home, have grab bars installed in the bathroom, and keep the stairs free of clutter. The client should not walk without proper footwear. Using one electrical outlet in the home could cause an electrical hazard.
52
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Laser surgery and photodynamic therapy are both treatments for what disease of the eye?
A) Congenital cataracts
B) Age-related cataracts
C) Nonexudative macular degeneration
D) Exudative macular degeneration
```
Answer: D
Explanation: A) Exudative (wet) macular degeneration may be treated by laser surgery or photodynamic therapy. Macular degeneration of the nonexudative (dry) kind is treated with high-dose antioxidants and zinc. Neither laser surgery nor photodynamic therapy is used to treat age-related or congenital cataracts.
53
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What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway?
A) Beta-adrenergic blockers
B) Prostaglandin analogs
C) Alpha2-adrenergic agonists
D) Cholinergic agonists
```
Answer: C
Explanation: A) Alpha2-adrenergic agonists both decrease production of aqueous humor in the eye and increase drainage of aqueous humor from the uveoscleral pathway. Beta-adrenergic blockers decrease the production of aqueous humor in the eye, but they do not increase drainage of aqueous humor. Prostaglandin analogs increase drainage of aqueous humor from the uveoscleral pathway, but they do not decrease aqueous humor production. Cholinergic agonists increase drainage of aqueous humor through the trabecular meshwork via pupillary constriction.
54
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b
Which best describes photophobia?
A) Fear of light
B) Aversion to light
C) Reactive to light
D) Need for light
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Explanation: A) Photophobia is a sensitivity to light that clients with angle-closure glaucoma may sometimes experience, so aversion to light is closest to describing photophobia. It is not necessarily fear; phobia can be fear or aversion. There are many different types of reactivity to light, but photophobia is specifically a negative reaction. Photophobia typically involves the avoidance of light, not the need for it.
55
Which statement about cataract surgery is correct?
A) Cataract surgery should be quick but may have to take place in stages.
B) Cataract surgery may only be done on an inpatient basis with general anesthesia.
C) Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule.
D) Cataract surgery is typically bilateral and can be performed in a single day.
Answer: A
Explanation: A) Cataract surgery should be quick because it typically is done on an outpatient basis with only local anesthesia. If the patient presents with bilateral cataracts, however, surgery is typically performed on only one eye at a time, with an interval of days to several weeks before surgery is performed on the second eye. Cataract surgery is not typically done on an inpatient basis and does not usually involve general anesthesia. Opacification of the remaining posterior capsule is a secondary cataract, which may form following cataract surgery and also should be removed. If a client has bilateral cataracts, the surgery to remove them would typically be performed on different days.
56
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The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment?
A) Eye pain and redness
B) Floaters in the visual field
C) Subconjunctival hemorrhage
D) Hyphema
```
Answer: B
Explanation: A) Of the choices listed, only floaters in the visual field are suggestive of retinal detachment. Eye pain and redness are not associated with retinal detachment. Although subconjunctival hemorrhage and hyphema may occur following a blow to the head, they are unrelated to detachment of the retina.
57
) A nurse working in the emergency department is caring for a client with an eye injury. The client describes spots in the field of vision. Based on this finding, which of the following is the nurse's priority concern?
A) The possibility that the client will immediately lose all vision
B) The possibility that the client will experience a progressive deterioration of vision
C) The possibility that the client will begin to experience intense eye pain
D) The possibility that the client's conjunctiva will become red and edematous
b
Explanation: A) "Floaters," or irregular lines or spots in the client's field of vision, are a symptom of retinal detachment. With retinal detachment, the client is at risk for progressive deterioration of vision. Complete vision loss would be more likely with penetrating or perforating trauma or burn injuries. A red, edematous conjunctiva is more likely with burns. Intense eye pain is more likely with corneal abrasions or a foreign body being on the conjunctiva
58
A client comes into the emergency department with an eye injury. Which assessment findings suggest that this injury is the result of blunt trauma? Select all that apply.
A) Lid ecchymosis
B) Eye pain and decreased sharpness of vision
C) Photophobia and eye tearing
D) A well-defined bright area of erythema under the conjunctiva
E) A feeling of something in the eye
A, B, D
Explanation: A) Blunt trauma to the eye can cause lid ecchymosis, or a black eye, and subconjunctival hemorrhage, which would be indicated by a well-defined bright area of erythema under the conjunctiva. Decreased visual acuity (sharpness of vision) and eye pain can occur because of trauma-related hyphema, or bleeding into the anterior chamber of the eye. A feeling of something in the eye is typically caused by a foreign body on the conjunctiva. Photophobia and eye tearing are most often seen in corneal abrasions, not blunt trauma.
59
Which client is most at risk for eye injuries?
A) A firefighter who wears all required safety gear on calls
B) A baseball player who wears nothing over the eyes
C) A self-employed home worker who wears ANSI Z87 eyewear when doing any household cleaning or yard work
D) A construction worker who wears OSHA-required eyewear at all times while on site
Answer: B
Explanation: A) Protective eyewear is estimated to prevent more than 90% of all injuries, but more than 78% of individuals with eye injuries reported not wearing eyewear at the time of injury. Based on this data, the baseball player is most at risk for eye injuries because of the lack of eye protection and the potential for getting hitting in the face with a ball. Although the firefighter and construction workers are in more dangerous lines of work, they are also taking the required steps to protect their eyes and so are less at risk. The home worker is likely to be at least risk for eye injuries and yet still uses appropriate eyewear when cleaning or doing yard work.
60
The nurse is planning a teaching seminar for parents of school-age children that focuses on eye safety. What should the nurse include in this educational session?
A) All children should wear goggles when playing outdoors at all times.
B) Sunglasses need only be worn during the summer months.
C) Supervise young children when lighting fireworks.
D) Keep sharp objects out of the reach of young children.
Answer: D
Explanation: A) Scissors, knives, and other sharp objects should be kept out of the reach of young children. Parents should not permit preschool-age children to handle or light fireworks, even with supervision. Eye protection should be worn when participating in sports that lead to eye injury, such as baseball or tennis; it is not necessary at all times. Sunglasses should be worn whenever a child is exposed to bright light outdoors, regardless of the season.
61
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A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this client?
A) Risk for Infection
B) Anxiety
C) Acute Pain
D) Risk for Injury
```
Answer: D
Explanation: A) Immediate intervention is required for a client with a detached retina to prevent permanent injury and preserve vision. Thus, the priority nursing diagnosis for the client would be Risk for Injury. The client will most likely demonstrate anxiety with the loss of vision; however, preventing permanent retinal injury is the priority. Risk for infection would not be a priority until the retina is reattached. A detached retina is not typically accompanied by pain.
62
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) A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?
A) Apply anesthetic drops.
B) Apply eye ointment.
C) Remove the object.
D) Stabilize the object.
```
Answer: D
Explanation: A) For a severe or penetrating injury, promote rest and stabilize the injured eye by applying an eye pad or gauze dressing loosely over both the affected and unaffected eye. Stabilize any penetrating object, if possible. These measures reduce eye movement and can help preserve the client's vision. Anesthetic drops would be appropriate prior to the removal of a foreign body from the eye. Removal of a foreign body from the eye is appropriate, but not removal of a penetrating object, which could cause additional tissue damage. Use of eye ointment would be applicable after the removal of a foreign body or for a corneal abrasion.
63
A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye. Based on this data, what should the nurse do next?
A) Note a deterioration in vision.
B) Administer ultrasonography to assess the eye for a detached retina.
C) Compare this data to the initial assessment.
D) Note an improvement in vision
Answer: C
Explanation: A) An initial assessment provides valuable information about the effect of the injury on the patient's vision and a baseline for future comparisons. In this case, if the client had been unable to see through the injured eye and now is able to see shadows and movement, that would indicate an improvement in vision. Deterioration in vision would be indicated by a lack of sight, but there is no way to know whether the client's condition has improved or worsened without comparing it to the baseline. The client's ability to see shadows and movement does not indicate the need for ultrasonography, but basic diagnostic testing of the eye's acuity and pupil reactivity and size is warranted.
64
The nurse is caring for a client with a corneal abrasion. Which collaborative intervention should the nurse anticipate being included in the client's care?
A) Bedrest and an eye shield
B) Surgery
C) Applying antibiotic ointment and an eye shield
D) Flushing the eye with normal saline
Answer: C
Explanation: A) Applying antibiotic ointment would be indicated in the care of the client with a corneal abrasion. An eye shield such as an eye patch is further indicated because of the client's likelihood of rubbing the eye. Flushing the eye with normal saline is indicated for a burn injury to the eye. Surgery is indicated for penetrating injuries to the eye but is usually not necessary for corneal abrasion. Bedrest with an eye shield would be indicated for the care of the client with a blunt trauma to the eye.
65
The nurse is providing teaching to an older adult client related to avoiding eye injury. What should the nurse identify as an intervention to address the number-one cause of eye injuries in older adults?
A) Turning down the temperature of the client's home water heater
B) Storing all harsh chemicals out of easy reach
C) Ensuring the client wears protective goggles when engaging in outdoor activities
D) Addressing slippery floors and other fall hazards in the client's home
Answer: D
Explanation: A) The number-one cause of eye injury in older adults is falling. Primary causes of falls in older adults include slipping on wet surfaces and falling down stairs, so addressing fall hazards such as slippery floors would best prevent eye injuries for this client. Ensuring an appropriate water heater temperature would prevent scalds but does not specifically address risk of eye injury. Wearing eye protection is a good idea when participating in certain sports, but it is not necessary at all times and does not reduce the risk of fall-related injuries. Storing chemicals out of reach is probably not necessary unless there are children in the home; furthermore, keeping chemicals in a place that requires use of a stepstool or ladder may actually increase an older adult's risk of falls.
66
Which statement is true?
A) Eye injuries almost always take place in the home.
B) Construction workers have a reduced risk of eye injury because of the many protective measures they take.
C) The pathophysiology of an eye injury depends on the nature of the injury.
D) Eye injuries are relatively uncommon with advances in safety and risk prevention.
Answer: C
Explanation: A) The pathophysiology of an eye injury depends on the nature of the injury. Eye injuries may take place in the home, but they may also occur in other settings such as recreational sports events and the workplace, and adults who are at greatest risk of eye injuries include contractors, woodworkers, welders, and electricians, all of which occupations are heavily involved in construction work. Eye injuries affect more than 2.5 million Americans every year. Each year 50,000 people will permanently lose all or part of their vision as a result of injury.
67
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Foreign objects commonly cause what type of injuries among migrant farm workers?
A) Burns
B) Blunt trauma
C) Penetrating trauma
D) Abrasions
```
Answer: C
Explanation: A) Eye injuries among migrant farm workers are underreported. These individuals are exposed to a variety of risks such as chemicals, machinery, tools, and airborne soil and particulates. In one study, most reported eye injuries among migrant farm workers were penetrating wounds or open wounds, typically caused by foreign objects. An abrasion might not be an open wound, blunt trauma does not break the skin, and burns are not typically caused by foreign objects.
68
What does it mean to say that a corneal abrasion causes a disruption of the superficial epithelium of the cornea?
A) Such injuries are typically painless.
B) The superficial epithelium is completely removed.
C) The integrity of the superficial epithelium is disturbed.
D) The surface of the cornea sustains penetrating trauma.
Answer: C
Explanation: A) A disruption is a disturbance, in this case to the integrity of the superficial epithelium. An abrasion is not a penetrating injury. Objects that commonly cause corneal abrasion include contact lenses, eyelashes, small foreign bodies such as dust and dirt, and fingernails. Drying of the eye surface and chemical irritants also may result in a corneal abrasion. Superficial corneal abrasions typically heal quickly but are extremely painful. Completely removing the superficial epithelium would destroy the eye.
69
Which of the following statements best describes the physiologic response of the layers of the eye in response to a penetrating injury?
A) They pull away from the penetration.
B) They reform following the penetration.
C) They degenerate and atrophy immediately.
D) They begin to tear away from one another.
Answer: B
Explanation: A) In a penetrating injury, the layers of the eye spontaneously reapproximate (join together) after entry of a sharp-pointed object or small missile (e.g., a BB) into the globe. They do not pull away from the penetration, immediately degenerate and atrophy, or begin to tear away from one another.
70
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) A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which condition?
A) Idiopathic peripheral neuropathy
B) Mononeuropathy
C) Polyneuropathy
D) Hereditary peripheral neuropathy
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Answer: C
Explanation: A) Polyneuropathies, the most common types of neuropathy associated with diabetes, are bilateral sensory disorders. The manifestations appear first in the toes and feet and progress upward. The fingers and hands also may be involved, but usually only in later stages of diabetes. Mononeuropathies are isolated and affect only single nerves; they are commonly associated with injury or trauma. An idiopathic peripheral neuropathy would have no known cause, but for this client diabetes would be a likely cause of neuropathy, and diabetes is not hereditary, so there is no reason to suspect hereditary peripheral neuropathy.
71
The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this condition?
A) Working as an automobile mechanic on weekends
B) Playing tennis every Saturday
C) Drinking one six-pack of beer per day
D) Typing on the computer for several hours each day
Answer: C
Explanation: A) The client has a daily alcohol intake of one six-pack of beer. Alcohol abuse is a risk factor for the development of acquired peripheral neuropathy, so the client should be discouraged from drinking. Typing on the computer for several hours each day might cause some localized nerve compression in the wrists but would not contribute to peripheral neuropathy. Working as an automobile mechanic and playing tennis would not cause peripheral neuropathy.
72
The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client's false perception that socks are being worn is accurate?
A) Confusion is a part of this disorder, so the client is simply confused as to whether socks are being worn.
B) This disorder causes a change in sensation that makes the client feel as if socks are being worn.
C) The medications used to treat this disorder cause the client to feel as if socks are being worn.
D) Tactile hallucinations are part of this disorder, so the client is hallucinating that socks are present.
Answer: B
Explanation: A) Changes in sensation related to Guillain-Barré syndrome frequently cause a "stocking-glove" pattern—in which clients feel as if stockings and gloves are being worn when they are not—as well as pain in the hands, feet, and legs. Tactile hallucinations and confusion are not part of the disorder. Medications are not causing the client to feel as if socks are being worn.
73
A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this time?
A) Anxiety
B) Ineffective Peripheral Tissue Perfusion
C) Ineffective Coping
D) Chronic Pain
Answer: D
Explanation: A) The client reports aching legs and an inability to be comfortable. The nursing diagnosis most appropriate for the client at this time would be Chronic Pain. Ineffective Peripheral Tissue Perfusion is the likely reason for the client's pain and discomfort, but the nurse's primary interventions for this client will relate to pain management, safety, and comfort, not to directly treating the cause of the pain. The client may have anxiety and be coping ineffectively, but the diagnosis of Chronic Pain is the priority.
74
The nurse is planning care for an adolescent client recently diagnosed with Charcot-Marie-Tooth syndrome. Which intervention is the highest priority?
A) Managing the client's chronic pain
B) Reducing the client's risk for injury
C) Addressing the client's perfusion problems
D) Relaxing the client to reduce stress
Answer: B
Explanation: A) In the early stage of Charcot-Marie-Tooth syndrome, the disease may manifest in clumsiness due to foot drop and muscle weakness in the feet, ankles, and legs, so addressing risk for injury is the priority for this client. As the client ages, chronic pain will likely become a concern, but not likely at this stage in the disease. Addressing problems with perfusion would not be the priority here, and even if the client feels stress-induced anxiety because of the illness, that is not a priority over ensuring the safety of the client.
75
The nurse is caring for a client who receives vitamin B12 injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and toes, and she asks the nurse what this means. How should the nurse reply?
A) "The tingling suggests that you are due for another injection."
B) "The tingling means that the injections are not producing their intended effect."
C) "The tingling is a common side effect of B12 injections."
D) "The tingling is most likely unrelated to your injections."
Answer: A
Explanation: A) Vitamin B12 injections are given to reduce tingling related to peripheral neuropathy. A recent increase in tingling suggests that the medication has been working but the client is due for another injection soon.
76
) Which client's clinical manifestations are most consistent with Guillain-Barré syndrome?
A) A 13-year-old client feels weakness in the feet, ankles, and legs.
B) A 5-year-old client feels leg pain and wants to be carried.
C) A 55-year-old client experiences a lack of hand strength.
D) A 23-year-old client with peripheral neuropathy has poor glycemic control.
Answer: B
Explanation: A) Children younger than 6 years old with Guillain-Barré syndrome may present with a refusal to walk and pain in the legs. The 13-year-old client's feeling of weakness in the feet, ankles, and legs is likely an early manifestation of Charcot-Marie-Tooth syndrome, whereas the 55-year-old client's lack of hand strength is likely due to more advanced CMT syndrome. The 23-year-old client with poor glycemic control is likely due to diabetes, which is probably the cause of the client's peripheral neuropathy.
77
The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this teaching?
A) Set the water heater at 120°F.
B) Avoid hand and foot massages.
C) Use a mirror to inspect feet daily.
D) Increase medication for pain as necessary.
Answer: C
Explanation: A) Using a mirror to inspect the feet daily is recommended because the client may not feel the formation of pressure points, blisters, or ulcers. Setting the water heater at 120°F is incorrect because it is too hot and the client may be scalded because of lack of sensation. Avoiding hand and foot massages is incorrect because this therapy will relax the client, increase the circulation, reduce the need for medication, and increase the psychologic benefits of touch, including the ability to be soothed, comforted, held, and loved. Increasing medication for pain as necessary is incorrect because it can further decrease touch sensation by clouding the sensorium and inducing lethargy, which requires additional supervision and monitoring to ensure safety.
78
Which of the following statements regarding idiopathic neuropathy is true?
A) Idiopathic neuropathy is hereditary in nature.
B) Idiopathic neuropathy has no known cause.
C) Idiopathic neuropathy is caused by nutritional deficits.
D) Idiopathic neuropathy is caused by disease or illness.
Answer: B
Explanation: A) Idiopathic neuropathies are from an unknown cause and account for up to 30% of neuropathies. These neuropathies are not hereditary and not caused by any identifiable factor such as nutrition or illness.
79
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Which degree of alcohol use has been implicated in the development of alcohol-related neuropathy?
A) Chronic and heavy
B) Short term and light
C) Intermittent and severe
D) Acute and toxic
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Answer: A
Explanation: A) Alcoholic neuropathy is damage to the nerves that results from long-term excessive use of alcohol, and so chronic and heavy are the best terms to describe the alcohol use that cause this type of peripheral neuropathy. This type of alcohol use is not short term, light, intermittent, or acute.
80
) Which statement regarding risk factors for peripheral neuropathy is accurate?
A) Extremely short people are at the highest level of risk for developing peripheral neuropathy.
B) Height is a risk factor for women but not a proven risk factor for men.
C) Height is a risk factor for men but not a proven risk factor for women.
D) Risk for peripheral neuropathy is proportional to height for both men and woman.
Answer: D
Explanation: A) Height has been identified as a risk factor for the development of peripheral neuropathy, independent of gender or presence of diabetes mellitus. Men who are taller than 167 cm (5 ft 6 in.) and women who are taller than 159 cm (5 ft 3 in.) are at higher risk for developing peripheral neuropathy than individuals of shorter height, and they are at higher risk of amputation if they do develop peripheral neuropathy.
81
Answer: D
Explanation: A) Height has been identified as a risk factor for the development of peripheral neuropathy, independent of gender or presence of diabetes mellitus. Men who are taller than 167 cm (5 ft 6 in.) and women who are taller than 159 cm (5 ft 3 in.) are at higher risk for developing peripheral neuropathy than individuals of shorter height, and they are at higher risk of amputation if they do develop peripheral neuropathy.
Answer: B
Explanation: A) Nursing informatics is the science of using computers in nursing practice to improve client care by making client information easily accessible for the client and other healthcare workers who are participating in the client's care. Documenting client information by computer does not necessarily reduce charting time, depending on the system used. The client's information is protected by privacy laws. Clients have the right to access their medical records regardless of whether they are paper or electronic.
82
) The nurse is part of the clinical information system committee at a major healthcare organization. When designing a plan to ensure the protection of client information, which approaches should the nurse suggest this committee include in the implementation plan? Select all that apply.
A) Design policies to address password protection and login information.
B) Determine how to handle clients who desire to "friend" staff through social media.
C) Identify applications that interface with smartphones.
D) Create interfaces so that health data can be inputted by the client.
E) Teach users to not leave protected health information unattended.
Answer: A, B, E
Explanation: A) The committee is creating a plan to ensure the protection of client information. The committee needs to design polices for password protection and login information, determine mechanisms to handle clients and staff who communicate through social media, and teach users to not leave protected health information unattended. Identifying applications that interface with smartphones and creating interfaces so that clients can input health data are not approaches to ensure the protection of client information.
83
The nurse is preparing discharge instructions for a client with a foot wound. How will the clinical information system support this client's learning needs?
A) Improves documentation about the client's status
B) Summarizes the list of charges that will appear on the client's bill
C) Provides a record of all medications received while hospitalized
D) Prints discharge instructions to use for teaching
Answer: D
Explanation: A) The clinical information system provides access to client information and provides data to help the nurse execute the nursing process. This includes printing discharge instructions to use in client teaching. Although different information systems can do all of these things, only printing discharge instructions will support the client's learning needs.
84
A rural home health nurse is caring for a client recovering from a myocardial infarction. The client is concerned that the community clinic does not have the ability to provide the necessary monitoring for the health problem. Which response by the nurse supports the use of informatics to meet client needs?
A) "It is not necessary for you to be monitored after a myocardial infarction."
B) "We can send your information to the cardiologist using telehealth."
C) "You are right. We will be sending you to the city every month."
D) "We use an intranet in this facility."
Answer: B
Explanation: A) Through telehealth advances, clients who live in remote areas can have their information monitored by specialists using computers. Because of this technology, clients do not need to make frequent visits to specialists for monitoring and evaluation of progress. A client who has experienced a myocardial infarction does require monitoring. The intranet is used within an agency or system and is not a tool that can be accessed from the outside.
85
The nurse is preparing an educational brochure to teach clients how to determine the validity of content obtained from health-related internet websites. Which information should the nurse plan to include in this teaching tool? Select all that apply.
A) Source for the information
B) Sponsor of the website
C) Ways to identify if the site is selling a product
D) Number of visitors to the website
E) Date the content was last reviewed
Answer: A, B, C, E
Explanation: A) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website.
86
A client diagnosed with cancer is receiving care through a facility that is 100 miles from the client's home. After the nurse explains how telehealth will be used to enhance this client's care, which client statements indicate that teaching about telehealth has been effective? Select all that apply.
A) "I will have to move closer to the provider."
B) "My health record can stay where I am."
C) "I can participate in the videoconference."
D) "I will have to change doctors."
E) "This will help lower some costs of care."
Answer: B, C, E
Explanation: A) Using telehealth, the client can live and stay in the home and does not need to move closer to the treatment or monitoring facility. The client will not be required to change healthcare providers. Telehealth allows for the client to participate in a videoconference, keep health records in the home agency, and lower many of the costs that could be incurred with frequent travel.
87
Which action by the nurse will help minimize the risk of eyestrain when engaging in computerized documentation?
A) Use a firm board to rest the palm.
B) Use an antiglare screen cover.
C) Obtain a paper chart for nursing documentation.
D) Use a lumbar support.
Answer: B
Explanation: A) An antiglare screen cover may decrease the eyestrain that the nurse is experiencing. The nurse will not be allowed to chart on paper because the nursing documentation is electronic. A firm, flat board or hard surface to rest the palm is the best way to protect the wrist from injury. A lumbar support helps with appropriate body posture for the back.
88
A group of staff nurses is discussing the importance of uniform language within healthcare documentation. Which statement made by the one of the nurses indicates an understanding of uniform language in healthcare documentation?
A) "Uniform language is useful only when communicating with other staff nurses."
B) "Uniform language is the consistent use of the same terminology among all providers."
C) "Uniform language decreases the value of nursing interventions in the eyes of other providers."
D) "HIPAA and HITECH are examples of uniform languages used by nurses."
Answer: B
Explanation: A) Uniform language is the consistent use of the same terminology among providers, facilities, institutions, and organizations. It is useful when communicating both with nurses and with providers from other disciplines. Uniform language can increase the visibility of nursing interventions and thus increase their value in the eyes of other providers. NANDA, NIC, and NOC are examples of uniform languages used by nurses, not HIPAA and HITECH.
89
) Which organization specifically focuses on improving healthcare quality, safety, and outcomes through improving the use of information technology (IT) and systems?
A) Healthcare Information and Management Systems Society (HIMSS)
B) American Medical Informatics Association (AMIA)
C) Alliance for Nursing Informatics (ANI)
D) Technology Informatics Guiding Educational Reform (TIGER)
Answer: A
Explanation: A) HIMSS works to improve healthcare quality, safety, and outcomes through improving the use of IT and systems. AMIA is dedicated to developing health informatics that support client care and teaching. ANI supports information leadership, practice, education, policy, and research. TIGER integrates technology and informatics competencies into nursing education and practice.
90
) What is the primary advantage of electronic reminders in the electronic health record?
A) They help nurses decrease the length of stay.
B) They help nurses increase client safety.
C) They help nurses document assessments.
D) They help nurses track quality metrics.
Answer: B
Explanation: A) The primary direct advantage of electronic reminders is that they help improve client safety, often by reminding nurses to use certain screening tools or complete certain assessments. By increasing safety, these reminders can indirectly reduce length of stay. Note, however, that electronic reminders don't actually help nurses document assessments, nor do they
91
Under which circumstance would the use of a geographic information system (GIS) be beneficial for healthcare workers?
A) When sharing a traveling client's electronic health record (EHR) with an out-of-state provider
B) During a mass casualty incident
C) When tracking the sleep pattern of a client
D) During an influenza outbreak
: D A GIS is used to map where infectious diseases are most likely to spread next so that adequate care can be provided. Although sleep patterns can be tracked using GIS, GIS is more beneficial when comparing sleep patterns in different geographic regions rather than tracking sleep patterns of one individual client. GIS is not typically used when sharing a traveling client's EHR with an out-of-state provider or during a mass casualty incident.
92
The nurse is caring for a client who has a condition that is not responding to standard interventions. How could accessing the clinical decision support system (CDSS) help with this client's care?
A) Provides evidence-based recommendations for care
B) Decreases the need to use critical thinking skills
C) Tells the nurse what the next step should be
D) Supports the nurse's "gut" instinct when providing care
Answer: A
Explanation: A) A CDSS uses a knowledge base and programmed rules, protocols, and guidelines developed using evidence-based guidelines to match against client data in the electronic health record (EHR) to deliver alerts or recommendations to the provider. The system will not provide a definitive next step for care, and the nurse still needs to use critical thinking skills to determine the best approach for the individual client. The CDSS may or may not support the nurse's "gut" instinct.
93
Which best describes how the use of a clinical decision support system can help the nurse plan care for a client with a particular condition?
A) It can help the nurse find out what was done on the previous admission.
B) It can help the nurse identify evidence-based guidelines for this client's condition.
C) It can help the nurse use standardized nursing language during documentation.
D) It can help the nurse search the internet for information about surgical procedures.
Answer: B
Explanation: A) Nursing care should always be based on evidence-based guidelines, which the nurse can access through a clinical decision support system. Although informatics can help the nurse find out what was done on the previous admission, use standardized language for documentation, and search the internet for information about the surgical procedure, none of these will help the nurse plan evidence-based care.
94
The nurse on the hospital research committee is assigned the task of compiling information related to the therapeutic and side effects of a specific drug. Which best describes how the nurse can use informatics to gain information about this topic?
A) Search for articles about the drug in the hospital's library.
B) Email other research committees to find out what they know about the drug.
C) Query electronic health records (EHRs) to determine client responses to the drug.
D) Look up the drug facts in the latest pharmacology textbook.
Answer: C
Explanation: A) Using computers, nurses can now query EHRs to research client responses to drug administration. Searching for articles in the library or looking up drug facts in a textbook does not require the use of informatics. Although emailing does use computers, emailing another research committee for information about a drug is not best practice for nursing research.
95
The nurse is facing a problem with a long-term care client that is different from anything encountered by the nurse in the past. What nursing action is appropriate prior to taking the problem to the research committee?
A) Perform a review of the literature.
B) Ask the client's family if this is a recurring issue.
C) Bring the problem up for discussion in the next staff meeting.
D) Ask the physician for assistance.
Answer: A
Explanation: A) When encountering a problem, the nurse can conduct a literature review to find applicable information. Asking the client's family if the problem is recurring will not help the nurse determine the course of care. The physician is not consulted for nursing problems. A staff meeting may provide some other opinions but will not give the nurse information regarding studies related to the client's problem.
96
In preparation for the next quality improvement committee meeting, the nurse accesses the clinical decision support system to run an outcomes report. How should the nurse anticipate the committee using this report?
A) To eliminate unnecessary care
B) To measure the length of hospital stays
C) To assist in modifying policies and procedures
D) To validate appropriate place of treatment
Answer: C
Explanation: A) Outcome tracking helps identify faulty processes and assists in modifying policies and procedures to improve client outcomes for a particular diagnosis or department within a health organization. Utilization review is designed to eliminate inappropriate or unnecessary medical care, length of stay, and place of treatment.
97
How does the clinical decision support system support human resource functions?
A) Determining if staff are correctly coding client care procedures
B) Identifying staff who are incorrectly charging for resources used for client care
C) Recognizing staff who are not discharging clients according to identified lengths of stay
D) Evaluating the number of staff with licensure due to expire
Answer: D
Explanation: A) Human resource departments can benefit from computerization by tracking personnel within the healthcare system. Professional licenses and credentials expire and must be renewed. It would be a daunting task to keep track of this information manually for a large facility that employs thousands of healthcare professionals. A computerized system can monitor license expiration and when recredentialing of a provider is required. Coding and charging for resources would be used by the billing department. Information about client discharges according to identified lengths of stay would be used in a utilization review.
98
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The nurse administrator of a local hospital is attending training on the new informatics system the hospital will be implementing. Which information should the nurse administrator be able to manage from the dashboard? Select all that apply.
A) Staffing
B) Budgets
C) Clients
D) Quality initiatives
E) Plans of care
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Answer: A, B, D
Explanation: A) Many electronic health records give administrators tools to manage budgets, staffing, quality initiatives, and productivity information. The use of dashboards puts all of this information at the administrator's fingertips. The dashboard does not include client-specific or identifying information, such as plans of care.
99
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Which factor increases nurses' use of clinical decision support systems (CDSS)?
A) Out-of-the-way workstations
B) Nursing experience
C) Caring for a new client
D) Reminder pop-ups
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Answer: C
Explanation: A) Nurses tend to use CDSS more frequently when they are caring for a client with which they are unfamiliar. However, nurses tend to decrease use of a CDSS when they have more nursing experience, when there are too many reminders, or when the workstation is not conveniently located.
100
Which administrative function related to medical records management may be made easier by the use of informatics?
A) Tracking client outcomes
B) Making sure charts are coded correctly
C) Ordering materials and supplies
D) Assigning a client to a hospital room
Answer: D
Explanation: A) All of these tasks are made easier through the use of informatics, but only assigning a client to a hospital room is related to medical records management. Tracking client outcomes is part of quality assurance, making sure charts are coded correctly is the job of the billing department, and ordering materials and supplies is related to facilities management.
101
What function might be made easier for healthcare organizations through the use of a computerized contract management system?
A) Tracking changes in reimbursement rates
B) Sharing information between billing systems
C) Managing material and supply inventories
D) Planning organizational budgets
Answer: A
Explanation: A) A computerized contract management system helps facilities track rates of reimbursement and real-time changes in policies for different health insurance plans. Financial systems help share information between billing systems, manage material and supply inventories, and plan organizational budgets.
102
) Several nurses are discussing the use of electronic medical records when providing client care. Which statements by the nurses indicate that they understand the advantages of electronic health records (EHRs)? Select all that apply.
A) "The record reduces the cost of healthcare."
B) "The record allows trending of client progress."
C) "Client education can be documented in the system."
D) "Quality metrics can be observed to reduce readmission rates."
E) "Coordination of care is improved."
Answer: B, C, D, E
Explanation: A) Electronic health records can assist the nurse by allowing trending of client progress, documentation of client education, and observation of quality metrics to help decrease readmission rates. Electronic health records also allow improved coordination of care between providers because they are all working off one chart. The use of the electronic health record does not directly reduce the cost of healthcare.
103
The nurse is providing discharge instructions about medications and exercise to a client who was hospitalized with a serious medical condition. Which action by the nurse ensures that the client is fully informed?
A) Make sure a relative attends the discharge teaching session.
B) Repeat the discharge teaching sessions twice.
C) Ask the physician to reinforce teaching prior to discharging the client.
D) Print the discharge instructions and hand them to the client prior to discharge.
Answer: D
Explanation: A) Most hospitals and agencies have computer-generated discharge instructions that the nurse can print to give the client to refer to when at home. This not only prevents calls, but gives the client confidence. Repeating the instructions does not help the client at home. Relatives can forget as easily as the client. It is not the physician's place to reinforce teaching.
104
Which statement regarding the term "point of care" is correct?
A) "Point of care" refers to the use of a portable device to provide care near the client.
B) "Point of care" refers to the location that nurses document care of the client.
C) "Point of care" refers to care that takes place away from the client.
D) "Point of care" refers to care that takes place in the client's home.
Answer: A
Explanation: A) One of the selling points of an electronic health record is that charting at point of care is possible, which helps to increase efficiency. Point of care refers to interventions or testing that takes place using a transportable, portable, or handheld device near the client. Point of care does not refer to the location where documentation takes place or to care that takes place away from the client or specifically in the client's home.
105
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Advances in technology have made what information available to healthcare providers at the client's bedside?
A) Vital signs
B) Radiologic images
C) Allergy alerts
D) Dietary restrictions
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Answer: B
Explanation: A) Even before many advances in technology, nurses and other healthcare providers had access to the client's current vital signs, allergy alerts, and dietary restrictions by viewing the client's paper chart at the client's bedside. However, they usually could not view radiologic images at the bedside. Now, with advances in technology, results from laboratory and radiologic exams can often be viewed at the client's bedside.
106
What is one advantage of the standardization of health records in relation to client education?
A) It allows the nurse to print information for the client rather than reviewing the information in person.
B) Families can receive education rather than clients in order to ensure that the client receives proper care at home.
C) Clients can receive the same education about their condition regardless of where they receive treatment.
D) Clients can look up their health information at home after discharge.
Answer: C
Explanation: A) Standardization of the health record allows clients to receive the same education about their condition regardless of where they receive treatment. Standardization does not negate the nurse's responsibility to review the information in person with the patient or family. Both families and client should receive education as appropriate, regardless of standardization. Clients looking up their health information at home does not depend on standardization of health records.
107
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The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply.
A) Reduction in elastin
B) Depleted moisture in epidermal cells
C) Decreased size of sebaceous glands
D) Thinner subcutaneous skin layer
E) Poor nutrition
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Answer: B, C, E
Explanation: A) As the individual ages, moisture transfer from the dermis to the epidermis declines. This contributes to a dry, rough skin appearance. Sebaceous glands also decrease in size with age, resulting in skin that is dry and easily bruised, damaged, or broken. Poor nutrition could also cause dry skin. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
108
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The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion?
A) Nodule
B) Macule
C) Scales
D) Crusts
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Answer: C
Explanation: A) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, to gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.
109
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The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity?
A) Poor turgor
B) Ascites
C) Peripheral edema
D) Hypothermia
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Answer: C
Explanation: A) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin's elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation.
110
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A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered?
A) Skin biopsy
B) Culture
C) Wood's lamp
D) Patch test
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Answer: B
Explanation: A) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.
111
A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin like my parents did as they got older." Which instruction by the nurse is appropriate?
A) Spend at least 15 minutes each day in the sun.
B) Increase the intake of calcium.
C) Increase the intake of dietary fat.
D) Avoid the sun or use a sunscreen to reduce skin damage.
Answer: D
Explanation: A) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun. The intake of dietary fat or calcium will not affect the development of liver spots.
112
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The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply.
A) Erythromycin
B) Bacitracin
C) Gentamycin
D) Desoximetasone
E) Desonide
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Answer: D, E
Explanation: A) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
113
) A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the educator include in the teaching session?
A) "The newborn's skin is about 40% to 60% thinner than an adult's skin at birth."
B) "The newborn's skin contains less water than an adult's and has tightly attached cells."
C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications."
D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."
Answer: A
Explanation: A) The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin has less subcutaneous fat compared to adults.
114
A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client. The nurse notes that the client has hypopigmentation of the skin on both hands. The nurse should recognize that this condition is related to which age-related skin change?
A) Hyperplasia of melanocytes
B) Decreased perfusion of the dermis
C) Increased permeability of the epidermal layer
D) Hyperplasia of capillaries
Answer: A
Explanation: A) Hyerpigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.
115
What does the nurse anticipate finding in a client with impetigo?
A) An infection in the hair follicles
B) Loss of skin color in blotches or sections
C) An itchy rash with clusters of fluid-filled vesicles
D) A fungal infection in the skinfolds
Answer: C
Explanation: A) Impetigo is a superficial skin infection common on the face, arms, and legs of children that presents as an itchy rash with clusters of fluid-filled vesicles that rupture easily. Ruptured vesicles develop a honey-colored crust over the lesions. Folliculitis is an infection of hair follicles. Vitiligo is a loss of skin color in blotches or sections that occur when the cells that produce melanin die or stop functioning. Candidiasis is a fungal infection commonly known as thrush and found in skinfolds.
116
A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology?
A) An immune response that leads to issues with tissue integrity
B) Impaired tissue integrity that leads to an immune response
C) Impaired tissue integrity that leads to an infection
D) Decreased perfusion that leads to issues with tissue integrity
Answer: A
Explanation: A) Allergic reactions are an example of an immune response that leads to issues with tissue integrity. Impaired tissue integrity, such as a cut, can lead to an immune response, but that is not the case in this scenario. If left untreated or exposed to bacteria or other infectious agents, the dermatitis could lead to an infection, but there is no evidence of that in this scenario. Decreased perfusion can lead to tissue damage or death, but not dermatitis.
117
) What impact might corticosteroids have on tissue integrity?
A) It may increase sensitivity to sunlight, leading to sunburns.
B) It may cause thinning of the skin, making skin more easily injured.
C) It may make skin appear shiny and lose its hair distribution.
D) It may cause the skin to become overly dry.
Answer: B
Explanation: A) Some medications, such as corticosteroids, cause thinning of the skin, making it much more easily damaged. Antibiotics, chemotherapy drugs, and some psychotherapeutic drugs increase sensitivity to sunlight and can predispose the individual to sunburns. Impaired peripheral arterial circulation in the lower extremities may produce skin that appears shiny and has lost its hair distribution. Excessive cleansing can cause the skin to become overly dry.
118
A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of
A) decreased hydration.
B) decreased blood flow to the skin.
C) inflammation and elevated body temperature.
D) hypothyroidism.
Answer: C
Explanation: A) Warm, red skin indicates inflammation and elevated body temperature. Decreased skin temperature is indicative of decreased blood flow to the skin. Excessively dry skin is indicative of hypothyroidism. Poor skin turgor is indicative of decreased hydration.
119
The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn?
A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only.
B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis.
C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation.
D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.
Answer: B
Explanation: A) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
120
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) A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified?
A) Minor
B) Moderate
C) Major
D) Significant
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Answer: C
Explanation: A) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
121
A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation?
A) Decreased osmotic pressure in the burned tissue
B) Reduced microvascular permeability at the site of the burned area
C) Increased potassium in the intracellular compartment
D) Inability of the damaged capillaries to maintain fluids in the cell walls
Answer: D
Explanation: A) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is a shifting of fluid volume that is the direct result of lost cell wall integrity at the injury site and in the capillary bed. There is an increase in microvascular permeability at the burn site. The osmotic pressure is also increased, causing fluid accumulation. Potassium ions leave the intracellular compartment, putting patients at risk for cardiac dysrhythmia due to hypokalemia.
122
Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply.
A) Part-time employment at a convenience store
B) Diagnosis of hypertension
C) Age 71 years
D) Uses public transportation for grocery shopping
E) Currently smokes one pack of cigarettes per day
Answer: C, E
Explanation: A) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, senses of smell and hearing, and because of impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
123
An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration?
A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase.
C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins.
D) The amount of urine output will be greatest in the first 24 hours after the burn injury.
Answer: B
Explanation: A) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
124
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A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time?
A) Ineffective Coping
B) Powerlessness
C) Anxiety
D) Situational Low Self-Esteem
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Answer: B
Explanation: A) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low self-esteem, ineffective coping, or anxiety.
125
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The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply.
A) Nutrition
B) Psychosocial support
C) Pain management
D) Fluid resuscitation
E) Wound care
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Answer: A, C, E
Explanation: A) Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.
126
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) The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status?
A) Creatine phosphokinase (CPK)
B) Blood urea nitrogen (BUN) levels
C) Hemoglobin
D) Albumin level
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Answer: D
Explanation: A) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent on the fluid status.
127
The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply.
A) Homograft
B) Application of a topical agent to dissolve necrotic tissue
C) Irrigation of the burn wounds
D) Application of wet-to-dry gauze dressings
E) Hydrotherapy
Answer: C, D, E
Explanation: A) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
128
How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg?
A) Place the client flat with the affected extremity abducted.
B) Elevate the head of bed 30 degrees
C) Maintain the head of bed flat
D) Elevate the affected extremity
Answer: D
Explanation: A) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.
129
The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true?
A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family.
B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members.
C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family.
D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family.
Answer: B
Explanation: A) The older adult population is more likely to suffer burns to a greater percentage of their TBSA than other age groups, largely because their skin is so much thinner and therefore more delicate than that of younger individuals. The other assumptions cannot be made based on patient age alone and depend on the depth and extent of the burns, which is information that is unavailable at this time.
130
An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because
A) she will have lower fluid resuscitation calculations than patients of normal weight.
B) she will be at greater risk for developing cardiac or renal insufficiencies.
C) she will require more supportive care than patients who are normal weight.
D) she will lose as much as 20% of her preburn weight during rehabilitation.
Answer: D
Explanation: A) During the acute and rehabilitative phases of the burn injury, the patient loses as much as 20% of preburn weight. This has significant implications for all patients, especially those who are underweight at the time of injury. Fluid resuscitation calculations are based on the time of injury, not body weight. Patients with a past medical history of cardiac or renal problems are at an increased risk for cardiac and renal insufficiency regardless of weight. Children and older adults require more supportive care than other client populations because of differences in their skin and healing, not because of their body weight.
131
) An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is
A) slightly higher than the normal range.
B) slightly lower than the normal range.
C) within the normal range.
D) extremely low.
Answer: A
Explanation: A) In adult patients with burn injuries who are receiving fluid resuscitation, urine production of 0.5-1 mL/kg/hr is considered normal. Therefore, the nurse would understand that this patient's output is slightly high.
132
A burn patient is currently in the acute stage. When did this stage begin, and when will it end?
A) It began with the onset of the burn injury and will end with fluid resuscitation.
B) It began with wound closure and will end when the patient's health is fully restored.
C) It began with the start of diuresis and will end with the closure of the burn wound.
D) It began with the onset of the burn injury and will end with the closure of the burn wound
Answer: C
Explanation: A) The acute stage begins with the start of diuresis and ends with the closure of the burn wound, either by natural healing or by use of skin grafts. The emergent/resuscitative stage begins with the onset of the burn injury and ends with successful fluid resuscitation. The rehabilitative stage begins with wound closure and ends when the patient returns to the highest level of health restoration, which may take years.
133
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A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use?
A) Partial-thickness loss of dermis
B) Nonblanchable erythema
C) Suspected deep tissue injury
D) Full-thickness tissue loss
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Answer: C
Explanation: A) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Nonblanchable erythema refers to a stage 1 pressure injury. Partial-thickness loss of dermis refers to a stage 2 pressure injury. Full-thickness tissue loss refers to stage 3, stage 4, and unstageable pressure injuries.
134
A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client?
A) Clean the pressure injury as needed.
B) Use hydrogen peroxide for chemical debridement of wound bed as needed.
C) Maintain the head of the client's bed at 30 degrees.
D) Avoid placing the client in the side-lying position
Answer: D
Explanation: A) The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.
135
) An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown?
A) Using the bed sheet to slide the client up in bed
B) Placing the bed in reverse Trendelenburg position
C) Using the client's arms to pull the client up in bed
D) Lifting the client, using the client's legs and arms for assistance
Answer: D
Explanation: A) The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.
136
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The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply.
A) Age 54
B) Body temperature within normal limits
C) Low serum albumin level
D) Continence of urine and stool
E) Prescribed bedrest
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Answer: C, E
Explanation: A) Risk factors for pressure injury development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure injury development. Although advanced age increases the risk of pressure injuries, this client is only 54 years old. Finally, normal body temperature does not increase the client's risk for pressure injury development.
137
An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client's sacrum. Which action by the nurse is appropriate to reduce the progression of this injury?
A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side.
B) Apply a heat lamp to the area to increase circulation.
C) Apply a dry dressing to the pressure injury.
D) Maintain the head of the bed at a 45-degree angle.
Answer: A
Explanation: A) Keeping the head of the bed at an angle of 30 degrees or less decreases pressure on the sacrum. An angle of 45 degrees would be too severe and could exacerbate pressure injury formation on the sacrum. Dry dressings are not indicated with this stage of pressure injury. Heat lamps are no longer used in the treatment of pressure injuries because they do not provide therapeutic benefit.
138
A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client?
A) Impaired Skin Integrity
B) Risk for Injury
C) Impaired Tissue Integrity
D) Ineffective Peripheral Tissue Perfusion
Answer: C
Explanation: A) Because a stage 3 pressure injury involves tissue, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure injuries result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity involves the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so Risk for Injury does not apply.
139
When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply.
A) Initiate a frequent toileting schedule.
B) Raise the client's heels off the bed.
C) Turn the client every 4 hours.
D) Use inflatable doughnut-style devices to reduce pressure on the sacrum.
E) Massage pressure areas with lotion every 4 hours.
Answer: A, B
Explanation: A) Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and the potential for skin breakdown. The client's heels should be raised off the bed to remove pressure on this area of the body. The client should be turned at least every 2 hours. Massaging pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, because they increase pressure and reduce perfusion to affected areas.
140
The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor?
A) The rubber doughnut pressure relief device was not delivered by central supply.
B) The client's serum albumin increased over the last month.
C) A right side-back-left side-back turning schedule was used.
D) Nurses did not document disinfection of the wound with alcohol at each dressing change.
Answer: C
Explanation: A) Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
141
) A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate?
A) "I will need to get an order from the physician."
B) "Using the doughnut can cause skin breakdown."
C) "You will need to wait until discharge, then use the doughnut at home."
D) "I will obtain the device for you.
Answer: B
Explanation: A) Use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened with use of the device, but this is due to the loss of sensation. Use of a doughnut-style device should be avoided whether at the hospital or at home.
142
A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate?
A) "I will need to obtain an order from the healthcare provider to perform a massage."
B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care."
C) "I will record these findings in the medical record."
D) "Massage may actually cause more harm to a potentially compromised area of skin."
Answer: D
Explanation: A) Redness may indicate the presence of a stage 1 pressure injury. Evidence suggests that massage over bony prominences like the coccyx can cause or worsen deep tissue trauma in patients at risk for a pressure injury. Massage should thus be restricted when problems are noted. Even when appropriate and therapeutic for a client, massages do not require a healthcare provider's order.
143
A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best?
A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage."
B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries."
C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity."
D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."
Answer: D
Explanation: A) Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.
144
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) What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
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Answer: B
Explanation: A) A stage 2 pressure injury is characterized by partial-thickness skin loss involving the dermis. It presents as a shallow open ulcer with a viable, moist wound bed that is red or pink. Granulation tissue, slough, and eschar are not present. A stage 2 injury may also present as an intact or open serum-filled blister.
145
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Softening of the skin as a result of prolonged wetting or soaking is also referred to as
A) maceration.
B) debridement.
C) excoriation.
D) shearing.
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Answer: A
Explanation: A) Maceration involves softening of the skin due to prolonged wetting or soaking. Excoriation is loss of the superficial layers of the skin. Debridement is the removal of necrotic material from a wound. Shearing occurs when one layer of tissue slides over another.
146
Which of the following clients would be the most appropriate candidate for autolytic debridement?
A) A 47-year-old client with a stage 2 pressure injury
B) A 68-year-old client with a suspected deep tissue injury
C) A 71-year-old client with a stage 1 pressure injury
D) A 59-year-old client with a stage 3 pressure injury
Answer: D
Explanation: A) Debridement, regardless of type, is typically reserved for pressure injuries with full-thickness tissue loss. This includes stage 3 pressure injuries, stage 4 pressure injuries, and (in some cases) unstageable pressure injuries. Thus, only the client with a stage 3 injury would be an appropriate candidate.
147
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A client has a laceration that was closed with tissue adhesive. By what process will this wound heal?
A) Tertiary intention
B) Secondary intention
C) Delayed primary intention
D) Primary intention
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Answer: D
Explanation: A) In primary intention wound healing, the edges of the wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Secondary intention healing involves wounds that cannot be approximated and that must "heal in." These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. With tertiary intention healing, also called delayed primary intention healing, wounds are left open for 3 to 5 days to allow edema or infection to resolve before being closed by sutures, staples, or adhesive skin closures.
148
A client recovering from abdominal surgery tells the nurse that "something popped" in his abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate? Select all that apply.
A) Notify the client's surgeon.
B) Pack the client's wound with nonadherent gauze.
C) Turn the client onto his abdomen.
D) Position the client in bed with his knees bent.
E) Cover the incision with a large, saline-soaked dressing.
Answer: A, D, E
Explanation: A) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound, and the client should not be turned onto his abdomen.
149
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An older adult client diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for a total knee replacement. What should the nurse include in this client's plan of care to address the risk of an alteration in tissue integrity?
A) Monitor urine output.
B) Assess postoperative wound healing.
C) Restrict protein intake.
D) Expect purulent drainage.
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Answer: B
Explanation: A) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. Furthermore, regardless of their chronic disease status, older adults often experience slowed healing as a result of normal cellular and molecular changes. Thus, it is critical that the nurse regularly assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need adequate protein for wound healing, so protein intake should not be restricted.
150
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A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a priority?
A) Situational Low Self-Esteem
B) Risk for Infection
C) Anxiety
D) Ineffective Coping
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Answer: B
Explanation: A) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.
151
The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this client?
A) The client will discharge to home as soon as possible.
B) The client will resume independent activities of daily living (ADLs).
C) The client will increase ambulation.
D) The client will regain intact skin.
Answer: D
Explanation: A) This client has impaired skin integrity because of a surgical wound. An appropriate goal of care would be for the client to experience wound healing to achieve intact skin. For a client who otherwise has good health, the other goals are appropriate, but they are not directly related to the surgical wound. However, for some patients, discharge to home, resuming independent ADLs, and increasing ambulation may not be appropriate goals.
152
The nurse is assessing a client with a surgical wound. Which finding indicates that care has been effective for this client?
A) The client's temperature is 100°F.
B) The client performs wound care independently.
C) There is only a scant amount of purulent drainage on the dressing.
D) A small area of erythema and edema is present.
Answer: B
Explanation: A) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.
153
An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs?
A) Assist with deep-breathing exercises.
B) Medicate for pain prior to dressing changes.
C) Request a dietary consult.
D) Encourage ambulation.
Answer: C
Explanation: A) The nurse should consult with a dietitian to identify ways to improve the client's intake to support wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
154
A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this client?
A) Positioning the client to keep weight off the wound
B) Positioning the client with weight directly on the wound
C) Restricting fluids
D) Enforcing strict bedrest
Answer: A
Explanation: A) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation, and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.
155
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A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. Three days after the debridement, the client's surgical wound was closed with staples that are aiding in healing. Given this information, which of the following terms should the nurse use when documenting this client's care?
A) Primary intention healing
B) Secondary intention healing
C) Tertiary intention healing
D) Quaternary intention healing
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Answer: C
Explanation: A) Wounds that are left open for 3-5 days to allow edema or infection to resolve or to permit exudate to drain and then are closed with sutures, staples, or adhesive skin closures undergo tertiary intention healing. Primary intention healing occurs where tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.
156
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A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples, and the nurse notes a "healing ridge" is present. Based on this information, the incision is currently in which phase of the healing process?
A) Inflammatory phase
B) Proliferative phase
C) Maturation phase
D) Synthesis phase
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Answer: B
Explanation: A) The proliferative phase, which is the second phase in the healing process, extends from day 3 or 4 to about day 21 postinjury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. There is no synthesis phase in the healing process, and the other choices are incorrect.
157
Which statement about wound care across the lifespan is correct?
A) "When applying transparent dressings on older adult clients, do not hold the skin taut, because doing so can cause damage."
B) "In young children, staph bacteria and fungi are the most common causes of infection in minor wounds."
C) "Pressure injuries and contact irritation are rare among newborns and infants in NICUs."
D) "As compared to younger clients, older adults have a heightened inflammatory response, which can contribute to delayed wound healing."
Answer: B
Explanation: A) Of these options, the only accurate statement is that the two major infectious agents affecting the skin of children are Staphylococcus and fungi. The rest of the statements are not valid. Specifically, the skin of older adult clients should be held taut when applying transparent dressings; pressure injuries and contact irritation are common among hospitalized newborns and infants; and older adults have a delayed inflammatory response as compared to younger clients.
158
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) Hemostasis and phagocytosis are characteristic of which stage of the wound healing process?
A) Inflammatory phase
B) Proliferative phase
C) Granulation phase
D) Maturation phase
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Answer: A
Explanation: A) The inflammatory phase of wound healing is initiated immediately after injury and lasts 3-6 days. Two major processes occur during this phase: hemostasis and phagocytosis. The inflammatory phase is followed by the proliferative and maturation phases. There is not a granulation phase of wound healing, although formation of granulation tissue occurs during the proliferative phase.
159
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Which of the following findings suggests that a wound is infected with pyogenic bacteria?
A) Sanguineous exudate
B) Serous exudate
C) Serosanguineous exudate
D) Purulent exudate
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Answer: D
Explanation: A) Purulent exudate is more commonly called pus, and it is created by microorganisms known as pyogenic bacteria. In contrast, sanguineous exudate consists of large amounts of red blood cells; serous exudate is clear or straw colored and has few cells; and serosanguineous exudate consists of both clear and blood-tinged drainage.
160
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Which of the following medications may be discontinued in a client who is experiencing delayed wound healing?
A) Oral prednisone
B) Topical antibiotics
C) Topical growth factors
D) Oral antibiotics
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Answer: A
Explanation: A) Oral prednisone is a steroid. Steroids are known to interfere with healing, so it is likely that use of these drugs may be discontinued. In contrast, topical and oral antibiotics may be appropriate for clients with delayed wound healing, because they can help prevent infection. Topical growth factors may also be applied to a wound in an attempt to "jump start" the healing process.
161
) The nurse is assessing a client's spirituality. Which of the following findings would suggest that the client experiences spirituality as a source of strength? Select all that apply.
A) The client uses the telephone to inform family members of an unwanted diagnosis.
B) The client reads spiritual material every evening.
C) The client asks to watch a religious service on television.
D) The client says she has no desire to meet with a chaplain.
E) The client tells the nurse she is convinced she will be punished in the afterlife.
Answer: B, C
Explanation: A) Regularly reading spiritual material and asking to watch a religious service on television are actions that suggest the client views spirituality as a source of strength. In contrast, focusing on possible punishment in the afterlife would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a chaplain might indicate spiritual distress, or it might indicate that the client either places little emphasis on spirituality or feels that his or her spirituality is a private matter. Discussing an unwanted diagnosis on the phone is unrelated to spirituality.
162
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While hospitalized, a client learns that a close friend has died suddenly. The client is crying and asking, "Why, God?" The nurse should correctly identify that the client is demonstrating which type of spiritual distress?
A) Physiologic
B) Psychologic
C) Treatment-related
D) Situational
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Answer: D
Explanation: A) Factors that may be associated with or contribute to an individual's spiritual distress include situational concerns, physiologic problems, and treatment-related concerns. Situational factors include the death or illness of a significant other, inability to practice one's spiritual rituals, or feelings of embarrassment when practicing them. Physiologic problems include having a medical diagnosis of a terminal or debilitating disease. Treatment-related factors include recommendation for treatment, surgery, dietary restrictions, or isolation. Psychologic is not a factor that contributes to spiritual distress.
163
The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for 1 hour prior to receiving it. Which action by the nurse is most appropriate?
A) Contact the healthcare provider to suggest an alternative form of nutrition because the client is refusing to eat or drink.
B) Provide the client with breakfast and morning medication and encourage the client to eat and take Communion some other time.
C) Find out when the hospital clergy will be distributing Communion and adjust the client's medications and breakfast accordingly.
D) Suggest that because the client is hospitalized, eating and drinking will not affect the Communion.
Answer: C
Explanation: A) The nurse should follow the client's expressed wishes regarding spiritual care and should not pressure them to relinquish any of their beliefs or practices. To support the client's spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly. The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client's needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternative forms of nutrition, because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion.
164
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While assessing a client's spiritual needs, the nurse asks, "What spiritual beliefs are important to you?" This question represents which step of the FICA assessment model?
A) Community
B) Address
C) Implication
D) Faith
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Answer: D
Explanation: A) Within the FICA assessment model for spirituality, faith is assessed by asking the question "What spiritual beliefs are important to you?" Implication is assessed by asking the client, "How is your faith affecting the way you cope?" Community is assessed by asking, "Is there is a community of like-minded believers with which you routinely meet?" Address is assessed by asking the client, "How can the healthcare team support your spiritual needs?"
165
When receiving nursing care, the client states, "I drink a small glass of warm water mixed with the juice of one lemon every morning because it helps to heal my body." Which action by the nurse is appropriate when providing care to this client?
A) Tell the client that cold water is better metabolized by the body.
B) Instruct the client that lemon juice is really a dose of vitamin C that helps with healing.
C) Provide the warm water and juice of a lemon.
D) Suggest the client delay the water and lemon until after morning medications.
Answer: C
Explanation: A) The nurse should follow the client's expressed wishes regarding spiritual care. To support the client's beliefs about healing, the nurse should provide the client with the warm water and lemon juice. The nurse should not instruct the client about the benefits of lemon juice being vitamin C. The nurse should also not suggest that cold water be used instead. Asking the client to delay drinking the water and lemon juice will not support the client's spiritual needs.
166
Which questions are appropriate for the nurse to ask when assessing the spiritual beliefs of a client? Select all that apply.
A) "How will being sick interfere with your religious practices?"
B) "Would you like a visit from your spiritual counselor or the hospital chaplain?"
C) "Are any particular religious practices important to you?"
D) "How is your faith helpful to you?"
E) "Because you indicated you are Catholic, I suppose you fast every Friday?"
Answer: A, B, C, D
Explanation: A) The question related to fasting on Friday is inappropriate because it assumes that a client follows all the practices of the client's stated religion. All other questions are appropriate for the nursing student to ask a client during an admission assessment while assessing spiritual and religious beliefs.
167
A nurse is admitting a client to the oncology unit. During the admission assessment, when the nurse asks the client about religious preference, the client states, "I am an atheist." The nurse should recognize that the client holds which belief?
A) The client believes that there is one God.
B) The client believes that there is more than one god.
C) The client believes that the existence of God has not been proven.
D) The client does not believe in any god.
Answer: D
Explanation: A) An atheist is an individual who does not believe in any god. Monotheism is the belief in the existence of one God. Polytheism is the belief in more than one god. An agnostic is an individual who doubts the existence of God or a supreme being or who believes that the existence of God has not been proven.
168
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The family members of a critically ill client tell the nurse, "We believe in the power of prayer. Prayer connects us all and makes us stronger. We will continue to pray that our loved one recovers." This statement suggests that the family is demonstrating which of the following characteristics?
A) Good family support system
B) Spiritual well-being
C) Denial
D) Spiritual distress
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Answer: B
Explanation: A) Through their statement, the family members express the belief that they are connected by a higher power. They also say they draw strength from this belief. This is evidence of spiritual well-being, not spiritual distress. The family may or may not be denying the client's health status. Although this statement indicates that the family turns to a higher power for support, it does not reveal anything about the family's overall support system.
169
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Prior to being discharged, a client tells the nurse, "I trust you and the rest of the medical team, and I think the prescribed treatment is going to work. I'm ready to embrace life, and I'm looking forward to celebrating the holiday season in a few months." This statement suggests that the client is experiencing which of the following?
A) Spiritual well-being
B) Denial
C) Conflict
D) Apprehension
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Answer: A
Explanation: A) The client speaks of trusting relationships, hope, and a feeling of being alive and ready to embrace what the future brings. This suggests the client is in a state of spiritual well-being. The client's statement is not suggestive of denial, apprehension, or conflict about the future.
170
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A client was recently diagnosed with alcoholic liver cirrhosis. During a regular checkup, the client tells the nurse, "This is God's punishment for all those parties I went to when I was younger." The nurse should recognize that this religious view could have a negative effect on what other nursing concept?
A) Addiction
B) Legal Issues
C) Stress and Coping
D) Digestion
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Answer: C
Explanation: A) Clients can use religion as either a positive or a negative coping strategy. Negative expressions of religious coping include statements like "God is punishing me." If the client is addicted to alcohol, the diagnosis and religious belief may stimulate the client to give up alcohol, which would not be a negative effect. There are no legal issues present due to this client's statement. This religious view is unlikely to affect the client's digestive processes, although the disease itself may reduce metabolism associated with digestion.
171
The nurse is caring for a devout Muslim client who is near death. The nurse should be prepared for which request from the client related to religious beliefs?
A) Turn the client's head or body toward Mecca.
B) Have a spiritual leader perform the Anointing of the Sick.
C) Read the client the Tibetan Book of the Dead.
D) Perform a ritualistic bath for cleansing the body.
Answer: A
Explanation: A) Muslims who are dying often want their body or head turned toward Mecca, and they are encouraged to say the prayer recognizing their loyalty to Allah. Roman Catholics may request having a spiritual leader perform the sacrament of Anointing of the Sick. Tibetan Buddhists may read the Tibetan Book of the Dead within 7 days after death, but not before death. Ritualistic bathing of the body is usually performed by some religions, including Muslims, after death, not before death.
172
) The nurse is caring for an 8-year-old client who has been in the hospital repeatedly due to complications from leukemia. The nurse understands that the family is very religious, and the client often speaks about God's care for her. Which age-appropriate nursing intervention should the nurse implement that can help the child express her spirituality?
A) Help the child reminisce about fun experiences earlier in life.
B) Provide the child with tools to draw and color pictures.
C) Provide the child with tools to produce a music video.
D) Support parent-child bonding to encourage attachment.
Answer: B
Explanation: A) Nurses can support the spiritual well-being of the child by age-appropriate activities that allow nonverbal expression of faith, including drawing, coloring, painting, play, or music, depending on the child's interests or energy level. Producing a music video is more appropriate for adolescent clients. Supporting parent-child bonding is more appropriate for infants. Reminiscing about the past is more appropriate for older adults.
173
The nurse is caring for an older adult client with advanced dementia. The family often mentions that the client was very spiritual earlier in life and loved to sing. What could the nurse suggest to the family to help support the client's religious needs?
A) They should help the client reminisce about spiritual events early in life.
B) They should encourage the client to compose lyrics or write music to a new spiritual song.
C) They should sing some of their favorite songs to the client.
D) They should bring in a recording of some of the client's favorite spiritual songs for him to listen to.
Answer: D
Explanation: A) One way that clients with dementia can worship is through various art forms, including music. This is an especially appropriate option for this client, given his history of spirituality and a love of singing. Letting the client listen to some favorite of his spiritual songs will give him an opportunity to enjoy an enriching spiritual experience without being pressured to participate, generate new ideas, or remember events from the past.
174
The nurse is providing care to a client who has just received a diagnosis of cancer. Which findings would suggest that the client is experiencing spiritual distress? Select all that apply.
A) Client is observed crying with children.
B) Client tells the nurse that he feels hopeless.
C) Client discusses possible outcomes with healthcare provider.
D) Client turns off a religious show on the TV and stares out the window.
E) Client is talking quietly with spouse.
Answer: B, D
Explanation: A) Spiritual distress may be characterized by expressions of a deficit in meaning, purpose, hope, forgiveness, or intimacy with the divine, or by anger or a lack of interest about previously spiritually nurturing persons or resources. Telling the nurse he feels hopeless and turning off a religious TV show indicates spiritual distress. The other actions are normal responses to a cancer diagnosis.
175
The nurse is planning care for a hospitalized client. Which activities should the nurse identify as appropriate to support the client's spiritual needs through presencing? Select all that apply.
A) Being available to the client
B) Sharing about a time when the nurse overcame a similar situation
C) Reading a newspaper at the nurse's station
D) Stating personal religious beliefs
E) Listening to the client
Answer: A, E
Explanation: A) Features of presencing include being available to the client and listening. Stating personal religious beliefs, reading a newspaper, and sharing about a time when the nurse overcame a similar situation are not characteristics of presencing.
176
A nurse is caring for a client who was recently diagnosed with a terminal illness. Which statement made by the client would indicate to the nurse that the client is in spiritual distress?
A) "I am not sure why this is happening but I believe God has a plan for me."
B) "I wish I did not have cancer but I believe that it is happening for a reason."
C) "My children don't go to church and they are having a difficult time dealing with my diagnosis."
D) "People tell me things happen for a reason, but why is God doing this to me?"
Answer: D
Explanation: A) The statement "But why is God doing this to me?" is reflective of spiritual distress. The client is not demonstrating being able to find a purpose and is also demonstrating a disconnect between herself and her higher spirit. The other answers do not indicate spiritual distress of the client.
177
A nurse enters a client's room to assess why the alarm on an IV infusion has sounded. As the nurse checks the IV equipment, the client says he would like someone to pray with. How should the nurse address the client's spiritual needs while providing necessary IV care?
A) The nurse should focus her attention solely on the infusion, because it is more important at this time than the client's prayer request.
B) The nurse should nod in response to the client's request while taking care of the infusion.
C) While taking care of the infusion, the nurse should offer to call a clergy member.
D) After assessing that the alarm is not an emergency, the nurse should offer to pray with the client.
Answer: D
Explanation: A) The nurse can best address this client's spiritual needs by being fully present with the patient and not being distracted by other tasks such as assessing the IV infusion. Although the nurse's first priority is to assess that the alarm is not an emergency, she can then stop and be fully present by listening to the client's request and offering to pray with the client. The other options do not indicate that the nurse is fully present with the client.
178
The nurse is performing a holistic assessment of a client. Which observations indicate that the client is experiencing spiritual distress? Select all that apply.
A) The client is sitting in a chair before breakfast reading the Bible.
B) The client states he has lost his faith in God since he's gotten ill.
C) The client is watching a religious program on the television.
D) The client is crying, pacing, and mumbling about God being angry with him.
E) The client is overheard arguing with clergy about the existence of God.
Answer: B, D, E
Explanation: A) The client who states a loss of faith in God after getting ill, the client who is crying, pacing and mumbling about God being angry with him, and the client who is overheard arguing with clergy about the existence of God may all be experiencing spiritual distress. The client who is observed sitting in a chair before breakfast reading the Bible or who is watching a religious program on the television is demonstrating a behavior of spiritual health.
179
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The nurse recognizes that a client is experiencing spiritual distress due to the need to receive a blood transfusion. The nurse should also identify the need to provide interventions for what other nursing diagnosis?
A) Decisional Conflict
B) Chronic Confusion
C) Acute Pain
D) Self Neglect
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Answer: A
Explanation: A) Some clients have religious beliefs that prevent them from receiving any blood products. If a client has a life-threatening condition that requires a blood transfusion, the client may have spiritual distress related to the conflict between religious beliefs and lifesaving medical treatments. This causes Decisional Conflict for the client. This conflict between beliefs and treatments would not likely cause Chronic Confusion, Acute Pain, or Self Neglect.
180
The nurse is caring for a client in spiritual distress. The client has met with the hospital chaplain but did not find it beneficial. The nurse recognizes that outside assistance from the client's own spiritual advisor may be helpful. What should the nurse do before making an appointment with the advisor?
A) Consult with the primary care provider to find an available counselor.
B) Ask the client's permission to contact the counselor.
C) Call the hospital chaplain to come speak with the client.
D) Advocate with the primary care provider to offer spiritual care to the client.
Answer: B
Explanation: A) The client's permission is needed before seeking an outside counselor in order to protect the client's right to confidentiality. Therefore, the nurse should ask the client's permission before contacting the counselor. The nurse does not need to consult with the primary care provider to find an available counselor, nor should the nurse ask the primary care provider to offer spiritual care to the client. Although the nurse could call the hospital chaplain to come speak with the client, this is not required before scheduling an appointment with an outside counselor.
181
While helping a client with the evening meal, the nurse observes the client close his eyes, bow his head, and murmur words of thanks and praise. What should this behavior suggest to the nurse?
A) The client did not want the nurse to leave.
B) The client was asking that the meal be better than the last.
C) The client is confused.
D) The client was praying before eating.
Answer: D
Explanation: A) The client's behavior of bowing the head, closing the eyes, and murmuring words of thanks and praise are indications that the client was praying. The client was not demonstrating confusion. The nurse has no way of knowing if the client was asking that the meal be better than the last. The client was not delaying the nurse so that she did not leave.
182
A client requests that surgery be delayed for several days until after a period of Holy Days has concluded. Which action by the nurse supports this client's request?
A) Remind the client that one's health is more important than following Holy Days.
B) Provide the client with alternative forms of treatment to replace having surgery.
C) Suggest the client think about whether having the surgery is the right decision, as the client is willing to delay it now.
D) Communicate the client's request to the surgeon.
Answer: D
Explanation: A) To support the client's need to avoid surgery during Holy Days, the nurse should communicate the client's request to the surgeon. The nurse should not remind the client that health is more important than following Holy Days or suggest that the client consider not having surgery. The nurse should also not provide the client with alternative forms of treatment to replace having surgery, as this is outside the nurse's scope of practice.
183
) A client who is scheduled for surgery wants to continue to wear a religious medallion. Which actions by the nurse support the client's religious needs? Select all that apply.
A) Keep the medallion on the client but remove it once anesthesia is provided.
B) Ask the client if wearing a medallion is going to ensure a successful surgery.
C) Document that the medallion is being worn by the client.
D) Suggest the client not wear the medallion because it will most likely be lost.
E) Explain that the medallion can be safety pinned to the client's gown.
Answer: C, E
Explanation: A) The nurse should explain that the medallion can be safety pinned to the client's gown. This approach would ensure compliance with the client's religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medallion is being worn by the client. The nurse should not remove the medallion after anesthesia is provided. The nurse should not tell the client that the medallion will be lost if worn or confront the client by asking if the medallion is going to ensure successful surgery.
184
A client is abstaining from meat and dairy products during Lent and refuses to select these items when making meal choices. Which actions by the nurse support the client's nutritional and religious needs? Select all that apply.
A) Ask the healthcare provider to discuss the impact of the restricted diet on the client's health.
B) Provide soy milk products as supplements.
C) Add protein powder supplements to the client's water pitcher.
D) Ask the client what foods are typically consumed during this period of time.
E) Consult with a dietitian for food choices to meet the client's needs.
Answer: D, E
Explanation: A) The best interventions would be for the nurse to consult with a dietitian for food choices to meet the client's health and religious needs and ask the client what foods are typically consumed during this period of time. The nurse should not provide soy milk products as supplements because the client may not like them. The nurse should not ask the physician to talk about the restricted diet with the client. The nurse should also not provide protein powder supplements in the client's water pitcher.
185
The nurse is preparing to discharge a client from the hospital. Which actions by the client indicate that her religious needs were met during the hospitalization? Select all that apply.
A) Requesting and attending religious services in the hospital chapel
B) Thanking the nurse for contacting a priest to visit while hospitalized
C) Asking nurse for additional supplies to change dressings while at home
D) Refusing home care services because the client's daughter is a nurse and a Sunday school teacher
E) Asking the nurse whom to call if problems occur after surgery
Answer: A, B
Explanation: A) Evidence that a client's religious needs were met while hospitalized would be the client thanking the nurse for contacting her priest and the client requesting and attending religious services in the hospital chapel. Asking for additional supplies to change dressings at home, asking whom to call if she has any problems at home, or telling the nurse that she will not need home care are unrelated to spiritual care
186
The nurse is developing a plan of care for a devout Muslim client. Which intervention should the nurse anticipate being a priority for this client?
A) The client will be able to participate in observing Sabbath.
B) The client will be able to participate in daily prayer with a rosary.
C) The client will be able to participate in reading the Torah.
D) The client will be able to participate in prayer at specific times without interruption.
Answer: D
Explanation: A) Nurses working with Muslim clients should be aware that many Muslims pray five times a day, and when developing the plan of care they should take prayer times into consideration if this is important to the client. Observing the Sabbath is common to Christianity and Judaism. Daily prayer with a rosary is common to Catholicism. Reading the Torah is specific to Judaism.
187
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The nurse is providing care to several clients. Which clients are most likely to request a vegetarian diet due to religious beliefs? Select all that apply.
A) A Catholic client
B) A Jewish client
C) A Hindu client
D) An Episcopalian client
E) A Seventh-Day Adventist client
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Answer: C, E
Explanation: A) Of the individuals listed, the Hindu and Seventh-Day Adventist clients are most likely to be vegetarian because of their religious beliefs. The Jewish, Episcopalian, and Catholic clients may opt to abstain from certain types of food, but these clients are not likely to be vegetarian because of their religious beliefs.
188
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) The nurse is providing care to a Catholic client who describes herself as "extremely devout." Which treatment option is most likely to cause spiritual distress for this client?
A) Blood transfusion for anemia
B) Specialized cardiac diet
C) Elective termination of pregnancy
D) A below-the-knee amputation
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Answer: C
Explanation: A) Elective termination of pregnancy, or abortion, is the treatment most likely to cause a devout Catholic client spiritual distress. Blood transfusion, specialized cardiac diet, and below-the-knee amputation are less likely to cause this client spiritual distress because they are not prohibited by Catholic teaching
189
The nurse is caring for a client who is actively engaged in an organized religion. Based on this statement, the nurse knows that which of the following statements is most likely true?
A) The client believes in the presence of only one god.
B) The client knows other individuals from the same religion who may be available to offer emotional and spiritual support.
C) The client lives by the moral code of the Ten Commandments.
D) The client will require time set aside for prayer several times each day, and the nurse will need to work around this schedule.
Answer: B
Explanation: A) Individuals who are actively engaged in a specific religion are usually part of a religious community. Members of this community are often called upon for emotional and spiritual support, especially during times of hardship or illness. Without knowing the client's specific religion, the nurse cannot assume that the client believes in the presence of only one god, that the client will need to set aside specific times each day for prayer, or that the client lives by the moral code of the Ten Commandments.
190
) A young client is brought into the emergency department by a friend who says the client was "beat up" at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this client?
A) The client does not want the individual who did the beating to get in trouble.
B) The client does not know his parents.
C) The client does not want the school to get in trouble.
D) The client is a victim of interpersonal violence.
Answer: D
Explanation: A) The client's reluctance to provide parents' names or address could suggest the client is a victim of child abuse from parents rather than a victim of bullying at school. Either way, the client is clearly a victim of interpersonal violence. It is unlikely that the client does not know his parents. It is also unlikely that the client does not want to get the school or the individual who did the beating in trouble.
191
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A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this data?
A) A protective factor
B) A risk factor
C) A vulnerability factor
D) A precipitating factor
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Answer: C
Explanation: A) Vulnerability factors increase one's risk of being a victim of violence. The client with a walking disability avoids the possibility of a crime by not going out alone at night. A protective factor decreases the risk of perpetration and victimization. Risk factors increase the potential that one will perpetrate violence on others. Precipitating factors are those that give rise to a specific incident of violence.
192
A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply.
A) Explore options for self-development.
B) Improve quality of life by increasing self-esteem.
C) Explore options for help.
D) Convey safety.
E) Determine immediacy of danger.
Answer: C, D, E
Explanation: A) Short-term interventions for abuse include determining the immediacy of danger, conveying that the client has the right to be safe, and exploring options for help. Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults.
193
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) After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next?
A) Conducting a team assessment
B) Medicating for anxiety as prescribed
C) Notifying the police
D) Treating the injuries
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Answer: A
Explanation: A) If the nursing assessment reveals possible domestic violence, a primary focus will be treating the injuries. However, treatment is often done by a team, which means a team assessment needs to be conducted before treatment can take place. The police may need to be notified later. The degree of anxiety will determine whether the client needs medication.
194
The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is present?
A) Call the police to have the spouse arrested for assault.
B) Refuse to permit the spouse to visit with the client.
C) Call security to have the spouse removed.
D) Ask the client if there is anything that is needed at this time.
Answer: D
Explanation: A) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and their family members. The nurse should ask the client if there is anything that is needed at this time. The nurse should not refuse to let the spouse visit unless it is the client's wish to do so. The nurse should not contact security or the police unless requested by the spouse.
195
) The nurse is providing care to a child who has suffered abuse. Which nursing actions are appropriate? Select all that apply.
A) Ask the child what he did to cause his parents to beat him so badly.
B) Tell the child that the individual who hurt them is a bad person.
C) Follow protocols for mandatory reporting.
D) Remind the child that he did nothing wrong.
E) Ask the child what really happened.
Answer: C, D
Explanation: A) The priority nursing consideration regarding the abused child is to ensure the immediate safety of the child. Beyond that, the abused child needs to be encouraged to talk about the abuse but must also be protected from having to provide multiple reports. The nurse working with the abused child needs to say that he or she believes the child's story; the nurse also must reassure the child that he or she has done nothing wrong. The nurse should avoid making negative comments about the abuser and must follow established protocols for mandatory reporting, documentation, and use of available support services.
196
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The nurse is discharging a client who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse. The client states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw, we went to Rome." Based on this data, which phase of violence is the client experiencing?
A) The tension phase
B) The abusive phase
C) The honeymoon phase
D) The reconciliation phase
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Answer: C
Explanation: A) The tension phase of the cycle of violence occurs when communication fails and tension builds. The abusive phase occurs when there is a violent incident. The honeymoon phase occurs when the aggressor shows love and affection. The cycle of violence will continue unless intervention occurs, and there is no reason for the client to expect it will stop or anticipate reconciliation and healing.
197
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The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply.
A) Involvement in the community
B) Participation in family activities
C) Residing in an impoverished community
D) Academic failures at a young age
E) Success in school
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Answer: A, B, E
Explanation: A) Involvement in the community, participation in family activities, and success in school are all examples of protective factors. Protective factors decrease the risk of violence perpetration and victimization. Residing in an impoverished community is a predisposing factor. Academic failure at a young age is a risk factor for becoming a perpetrator.
198
A client is brought into the emergency department after being in a motor vehicle crash. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this client?
A) Breathing and ventilation
B) Circulation with hemorrhage control
C) Airway maintenance with cervical spine protection
D) Disability and neurologic assessment
Answer: C
Explanation: A) When caring for the trauma victim, the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern be airway maintenance with cervical spine protection.
199
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What type of communication should the nurse employ when caring for a client who has suffered trauma?
A) Assertive communication
B) Therapeutic communication
C) Passive communication
D) Aggressive communication
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Answer: B
Explanation: A) Nurses need to employ therapeutic communication to help clients work through the stress and fear of the traumatic event and ultimately accept that the situation they experienced cannot be reversed. Nurses should never use passive or aggressive communication techniques with clients. Assertive communication may be helpful in some circumstances, but it is not as important as therapeutic communication.
200
The nurse is caring for several clients in the emergency department. Which individual is a victim of community violence?
A) A 32-year-old woman who was beaten by her spouse
B) A 20-year-old man who was shot during a gang dispute
C) A 6-month-old girl who was abused by her mother
D) A 76-year-old man who was neglected at a care facility
Answer: B
Explanation: A) Gang violence is a type of community violence, so traumatic injuries sustained during a gang dispute would be categorized as community violence. The other examples are related to interpersonal violence.
201
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) An individual who has experienced which type of trauma is likely to be most resilient?
A) Intimate partner violence
B) Bullying
C) Rape
D) Natural disaster
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Answer: D
Explanation: A) Generally, survivors of natural disasters show resilience, and the stress responses do not become chronic or debilitating. Bullying and intimate partner violence may be ongoing, persistent stressors that prevent resiliency. Rape is an extreme traumatic event that may take months to years to recover from
202
A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply.
A) Confusion
B) Missing teeth
C) Apprehension when other children cry
D) Abrasions to the mouth, lips, and genitalia
E) Dehydration
Answer: B, C, D
Explanation: A) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia; missing teeth; and apprehension when other children cry. Dehydration and confusion are manifestations of elder abuse.
203
The nurse is providing care for a 2-year-old client. When assessing the client's risk for abuse, which factors increase this client's risk? Select all that apply.
A) The child has bruises on the knees and shins.
B) The child's parents are married.
C) The child is less than 3 years old.
D) The child is deaf.
E) The child's parents are unemployed and receive medical assistance.
Answer: C, D, E
Explanation: A) Risk factors for child abuse include poverty, age less than 3 years, and child disability or condition that requires a great deal of care. Marriage of the parents and bruises on the knees and shins are not risk factors for abuse.
204
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A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate?
A) Powerlessness
B) Risk for Other-Directed Violence
C) Ineffective Health Maintenance
D) Chronic Low Self-Esteem
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Answer: A
Explanation: A) Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.
205
The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client?
A) Assist the client to devise a safety or escape plan.
B) Encourage the client to take charge of the situation.
C) Offer to contact outpatient services if the client promises not to return home after discharge.
D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A
Explanation: A) A client who has been victimized by a partner should have a safety plan. This has the highest priority as the client's life is in danger. The client has no control over the partner, and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging the client to take charge is too general a statement to be helpful; the client needs specific tools to develop a safety plan. It may not be safe and feasible for the client to leave the situation right away, and resources should not be withheld if a client is unable to promise not to return home.
206
A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective?
A) "Everyone knows what my problems are, and there is nothing I can do about it."
B) "I am functioning fine now but I know that when problems come up again, I will ask for help."
C) "My friends tell me that I have improved so this is a good time to stop."
D) "It is so draining to deal with the same painful issues all of the time."
Answer: B
Explanation: A) The client acknowledging that future problems will come up indicates that the client has gained insight into problems. The client's willingness to ask for help shows that the client is prepared to continue with counseling when new problems arise. Stating that the process is draining and painful suggests that little progress has been made and that the client is looking to avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of treatment on the statements of others places emphasis on others and not on self-evaluation.
207
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An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply.
A) Poor hygiene
B) Dehydration
C) Intracranial trauma
D) Fecal impaction
E) Dislocations
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Answer: A, B, D, E
Explanation: A) The nurse suspecting elder abuse would assess for clinical manifestations associated with elder abuse. Some of those clinical manifestations are constant hunger or malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it is a clinical manifestation of child abuse.
208
The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate?
A) Contact adult protective services.
B) Call the healthcare provider immediately.
C) Assess the client's cultural traditions.
D) Contact the client's family.
Answer: C
Explanation: A) The most appropriate action for the nurse at this time is to assess the client's cultural traditions. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.
209
A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take?
A) Discuss what the nurse witnessed with the infant's mother.
B) Discuss what the nurse witnessed with the other nurses.
C) Report what the nurse witnessed and assessed to the authorities.
D) Call security to remove the father from the room.
Answer: C
Explanation: A) Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant's mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.
210
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Which of the following is a common element of abuse experienced by the victim?
A) Accidental injury
B) Feelings of control
C) Humiliation
D) Manipulation
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Answer: C
Explanation: A) Common elements of abuse include humiliation, intimidation, and physical injury. Injury associated with abuse is not accidental. Feelings of control and use of manipulation tactics are related to the perpetrator, not the victim.
211
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Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors?
A) Social learning theory
B) Psychopathology theory
C) Neurobiology theory
D) Environmental theory
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Answer: A
Explanation: A) Social learning theory explains that individuals learn violent tendencies through association with others and a reinforcement of the abusive behavior. Psychopathology theory suggests that some individuals who experience personality disorders and mental illnesses participate in family violence as a result of these illnesses. Neurobiology theory asserts that genetics plays a role in anger modulation and emotion control. Environmental theory is not related to the etiology of abuse.
212
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) Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain?
A) Ultrasound
B) X-ray
C) MRI
D) Blood test
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A) An ultrasound or CT scan of the abdomen can check for abdominal or organ injuries. An MRI of the spine will show spinal injuries. X-rays can detect fractured bones. Blood tests may be used to detect sexually transmitted diseases.
213
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An older adult man is transported to the emergency department after a motor vehicle crash. Which risk factors for the older adult could have contributed to the crash? Select all that apply.
A) Unsafe driving practices
B) Preexisting health conditions
C) Speeding
D) Texting
E) Reduced sensory perception
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B, E
Explanation: A) Older adults are at risk of motor vehicle crashes due to preexisting health conditions and decreased sensory perceptions. Younger adults are at risk of motor vehicle crashes due to unsafe driving practices, speeding, and texting or other distractions.
214
The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. Which is an appropriate client goal for the nurse to include in the plan of care?
A) The client will have adequate urine output.
B) The client will regain mobility.
C) The client will participate in self-care activities.
D) The client will be discharged to home.
Answer: B
Explanation: A) The client has sustained multiple lower extremity fractures. A goal of care for this client is for the client to regain mobility. An adequate urine output is important, but healing the client's fractures needs to be a goal of care. Participating in self-care activities and being discharged to home are also important; however, because the client sustained multiple fractures to the lower extremities, one goal of care must be focused on the client regaining mobility.
215
A client was admitted to the hospital after a crush injury to the chest. The client sustained multiple rib fractures, a collapsed lung, and several skin abrasions. After the client is stabilized, which nursing intervention would be a priority for this client?
A) Monitor urine output.
B) Assess vital signs.
C) Perform passive range of motion to all extremities.
D) Assist to deep breathe and cough every 2 hours.
Answer: D
Explanation: A) The client has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the client breathes deeply and coughs every 2 hours to mobilize secretions and prevent respiratory complications. Monitoring urine output and assessing vital signs are important but not the priority at this time. The client may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated.
216
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A client is admitted to the emergency department with an incomplete spinal cord injury after a fall from a roof. Which prescription does the nurse anticipate to decrease inflammation and nerve damage?
A) Hydrocodone (Vicodin)
B) Ibuprofen (Motrin)
C) Methylprednisolone (Medrol)
D) Xylocaine (Lidocaine)
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Answer: C
Explanation: A) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease inflammation and prevent nerve damage. Hydrocodone (Vicodin) is a pain relief medication. Ibuprofen (Motrin) is an anti-inflammatory given to clients to reduce swelling, such as joint swelling. Xylocaine (Lidocaine) is injected into the affected muscle to relieve pain and muscle spasms, such as muscle spasms related to whiplash.
217
The nurse at a local hospital is conducting a safety workshop for expectant parents addressing newborn injury prevention and car seat safety. Which statement made by a parent indicates a need for further teaching?
A) "My newborn should be in a car safety seat every time he is in the car."
B) "My baby can ride facing forward as long as he is in a convertible car seat suitable for an infant."
C) "My newborn should ride in a rear-facing car seat."
D) "Never place a rear-facing car safety seat in the front seat with an active passenger air bag."
Answer: B
Explanation: A) Infants should always ride in a rear-facing car seat, even if it is a convertible seat suitable for an infant. Therefore, the statement relating to the infant facing forward is incorrect and indicates a need for further instruction. The other statements are correct and indicate no need for further education.
218
A nurse is developing a plan of care for a client with traumatic injuries after a natural disaster. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.
Answer: C
Explanation: A) Assisting the client to turn at least every 2 hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. Turning the client every 8 hours will not reduce the risk of integumentary complications. Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications.
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What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.
A) Airway maintenance
B) Obtaining medical history
C) Ventilation assistance
D) Hemorrhage control
E) Hypothermia prevention
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What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.
A) Airway maintenance
B) Obtaining medical history
C) Ventilation assistance
D) Hemorrhage control
E) Hypothermia prevention
```
220
A client is brought into the emergency department after being assaulted. The provider suspects that the client has a spinal cord injury. Which diagnostic tests does the nurse anticipate based on the data collected? Select all that apply.
A) Computed tomography (CT) scan
B) X-ray
C) Ultrasound
D) Magnetic resonance imaging (MRI)
E) Positron emission tomography (PET) scan
Answer: A, D
Explanation: A) Both MRIs and CT scans can be used to assess spinal cord injuries, among other injuries. An x-ray will be performed for potential fractured bones. An ultrasound is performed if internal bleeding is suspected. A PET scan is used to look for disease within the main organs of the body
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Which cause of multisystem trauma is the leading cause of injury death in the United States?
A) Poisonings
B) Motor vehicle crashes
C) Assault
D) Natural disasters
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Answer: A
Explanation: A) Poisonings are the leading cause of injury death in the United States, and all causes of fatal injuries are also causes of multisystem trauma. Motor vehicle crashes are also a major concern because of the significance of injuries sustained, but they are not the leading cause of injury death. Assault and natural disasters are not leading causes of injury death.
222
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A client lost consciousness after being hit by a falling piece of equipment on a work site. What type of injury should the nurse assess this client for as the highest priority?
A) Fractured bones
B) Traumatic brain injury
C) Whiplash
D) Spinal cord injury
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Answer: B
Explanation: A) Loss of consciousness is a sign of traumatic brain injury, and any injury to the brain should be assessed with highest priority. Fractured bones and spinal cord injury may also need to be assessed depending on the location of the injury and the client's other clinical manifestations, but these would be a lower priority than assessing for traumatic brain injury. Whiplash usually results from a motor vehicle crash, so assessing for whiplash would be low in priority.
223
If a pregnant woman sustains multisystem trauma, in which order should assessment occur?
A) Primary assessment of the mother, secondary assessment of the mother, primary assessment of the fetus
B) Primary assessment of the mother, primary assessment of the fetus, secondary assessment of the mother
C) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the mother
D) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the fetus
Answer: B
Explanation: A) If a pregnant woman sustains multisystem trauma, the best treatment for the fetus is resuscitation of the mother. Therefore, the mother should be assessed first, then the fetus. Once both have been assessed and stabilized, then the secondary assessment of the mother should be performed.
224
During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the client's behavior?
A) The client thought there was an earthquake.
B) The client was reacting to the loud noise as a form of a flashback.
C) The client wanted to check the cause of the loud noise.
D) The client thought the assessment was concluded.
Answer: B
Explanation: A) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise
225
The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply.
A) Observed family member being raped and murdered
B) Restores antique automobiles as a hobby
C) Lives with spouse and has a garden
D) Has a history of anxiety disorder
E) Recently terminated from employment
Answer: A, D, E
Explanation: A) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
226
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A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply.
A) Difficulty sleeping
B) Hypovigilance
C) Alcohol abuse
D) Aggressive behavior
E) Hair pulling
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A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply.
A) Difficulty sleeping
B) Hypovigilance
C) Alcohol abuse
D) Aggressive behavior
E) Hair pulling
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A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is the priority for this client?
A) Fear
B) Anxiety
C) Post-Trauma Syndrome
D) Ineffective Coping
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Answer: C
Explanation: A) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
228
The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago. Which should the nurse include in the client's plan of care?
A) Guidelines on conducting activities of daily living
B) Information on the treatments available
C) Referral to local employment agency
D) Information on the need for adequate exercise
Answer: B
Explanation: A) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
229
The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply.
A) The client takes a sedative at least four times a day.
B) The client has been sleeping throughout the night.
C) The client keeps all of the lights on at home.
D) The client verbalizes future plans with family and friends.
E) The client will not enter a car with fewer than three people.
Answer: B, D
Explanation: A) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives four times a day is exhibiting behavior that indicates interventions have not been successful.
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) Which nursing interventions would be appropriate for a client demonstrating extreme anxiety related to posttraumatic stress disorder (PTSD)? Select all that apply.
A) Encourage the client to discuss what caused the syndrome to develop.
B) Provide a calm, quiet environment.
C) Give the client paperwork to complete while waiting to be assessed.
D) Ask the client what is causing the anxiety.
E) Reassure the client that the environment is safe.
Answer: B, E
Explanation: A) The client diagnosed with PTSD who is exhibiting extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of his or her safety. The client should not be given paperwork to complete. Asking the client what is causing the anxiety and encouraging the client to discuss what caused the syndrome to develop are not effective interventions for acute anxiety related to this disorder and should not be done.
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A client is admitted with a diagnosis of posttraumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, which medication prescription does the nurse anticipate for this client?
A) Propranolol (Inderal)
B) Prazosin (Minipress)
C) Risperidone (Risperdal)
D) Fluvoxamine (Luvox)
```
Answer: B
Explanation: A) Prazosin is an antihypertensive medication that may be prescribed for treatment and prevention of nightmares. Propranolol (Inderal) is a beta-blocker; its possible uses include management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an antipsychotic that may be used in the treatment of obsessive-compulsive disorder (OCD) or panic disorders. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of OCD.
232
A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the client's plan of care?
A) The client will report a reduction in or cessation of nightmares.
B) The client will report a decreased perception of anxiety.
C) The client will discuss emotions related to traumatic experiences.
D) The client will remain free from injury or harm.
Answer: D
Explanation: A) Ensuring that the client remains free of injury would be the priority goal. The client was admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety is a priority. The other goals are relevant to the care of the client; however, they are not the priority goals.
233
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A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD) who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client?
A) Disturbed Sleep Pattern
B) Post-Trauma Syndrome
C) Risk for Other-Directed Violence
D) Risk for Self-Directed Violence
```
Answer: D
Explanation: A) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
234
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Which individual has the highest risk of developing PTSD?
A) Victim of assault
B) Natural disaster survivor
C) Motor vehicle crash survivor
D) Military veteran
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Answer: D
Explanation: A) Although all of these individuals may develop PTSD, the incidence of PTSD is particularly high among military personnel who have been deployed in overseas combat.
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Which form of therapy might be used to help an individual with posttraumatic stress disorder (PTSD) visit the location where a traumatic event occurred?
A) Cognitive-behavioral therapy
B) Dual attention stimulus therapy
C) EMDR therapy
D) Exposure therapy
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Answer: D
Explanation: A) Exposure therapy assists the patient by gradually exposing them to elements of the traumatic event using writing, pictures, and visiting the place where the traumatic event occurred. Cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and dual attention stimulus are all forms of therapy that might be used to help treat an individual with PTSD, but these types of therapy do not involve visiting the location where the traumatic event occurred.
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) The nurse is assessing a 4-year-old child. Which assessment finding indicates to the nurse that the child might have suffered a traumatic event?
A) The child refuses to talk or answer questions when previously the child chatted constantly.
B) The child draws pictures of family when previously the child drew pictures of animals.
C) The child complains of a stomachache and has a fever.
D) The child plays quietly in a corner when previously the child sat on his mother's lap.
Answer: A
Explanation: A) Forgetting how to talk or not talking at all are signs of posttraumatic stress disorder (PTSD) in children under the age of 6. A child with PTSD may draw pictures that symbolize the trauma, not simple pictures of family or animals. Somatic complaints are more common in older adults with PTSD and likely indicate conditions other than PTSD in young children. Children with PTSD may behave recklessly or aggressively, not play quietly.
237
The nurse is assessing two clients: a 23-year-old man who recently returned from overseas deployment with the military and a 68-year-old man who served in the military during the Vietnam War. Both clients have been diagnosed with posttraumatic stress disorder (PTSD). Which statement did the nurse likely record from the 68-year-old man?
A) "I startle at every sudden noise I hear, whether it is loud or quiet."
B) "I haven't had much of an appetite lately, and I keep forgetting important things."
C) "I just want to go out and hit someone."
D) "I feel so guilty that I came home and three of my good buddies didn't."
Answer: B
Explanation: A) Older veterans may report more somatic complaints, such as loss of appetite, sleep disturbances, and cognitive problems, than younger veterans with PTSD. Older veterans are also less likely to have typical PTSD symptoms such as an exaggerated startle response and exhibit less depression, hostility, and guilt than younger veterans with PTSD.
238
) The nurse is caring for a victim of rape. Which interventions should the nurse include in the client's plan of care? Select all that apply.
A) Notifying an attorney for the client
B) Supporting the victim during the examination
C) Identifying the individual who committed the rape
D) Treating acute injuries
E) Providing referrals for follow-up care
Answer: B, D, E
Explanation: A) Priorities of nursing care include treating any acute injuries, supporting the victim during the examination, and providing referrals for follow-up care. Nursing priorities do not include identifying the individual who committed the rape or notifying an attorney for the client.
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A client, who was raped and refuses to see any male healthcare providers, tells the nurse that she had an "incident" that she does not want to talk about, and wants a bed by the door. Which nursing diagnosis is appropriate for the client?
A) Relocation Stress Syndrome
B) Readiness for Enhanced Power
C) Rape-Trauma Syndrome
D) Acute Confusion
```
Answer: C
Explanation: A) Rape-Trauma Syndrome can manifest itself in many ways depending on the client. Some clients, such as this one, exhibit fear, especially of individuals of the same gender as the attacker. Clients may also exhibit humiliation, shame, and distrust in others. This client is not displaying evidence of readiness for enhanced power. There is no evidence that the client is experiencing relocation stress syndrome or acute confusion.
240
) The nurse is providing care for a client who was the victim of sexual abuse 8 months ago. Which ongoing, long-term treatment goals are appropriate? Select all that apply.
A) The client's symptoms of anxiety and fear will decrease.
B) The client will involve significant others in the treatment plan.
C) The client will be able to verbalize legal rights.
D) The client will establish rapport and build a trusting nurse—client relationship.
E) The client will learn how to reconnect with others.
Answer: A, E
Explanation: A) Decreasing symptoms of anxiety and fear and learning how to reconnect with others may take months or years, whereas the other treatment goals can be met in the short term (hours to days). The nurse should have involved significant others in the treatment plan, established rapport, and made the client aware of legal rights immediately after the sexual abuse occurred.
241
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A client recovering from a rape tells the nurse that flashbacks do occur but can be managed. Which techniques should the nurse suggest to the client for managing flashbacks about the event? Select all that apply.
A) Restoring personal choice
B) Deep breathing
C) Muscle relaxation
D) Problem solving
E) Guided imagery
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Answer: B, C, E
Explanation: A) Techniques that the client can use to control flashbacks include muscle relaxation, deep breathing, and guided imagery. Problem solving and restoring personal choice are techniques to support coping behaviors.
242
A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate?
A) "The baby could always be given up for adoption."
B) "You will not know for sure for at least a few more days."
C) "Emergency contraception is available to prevent pregnancy."
D) "Are you sure the rapist did not use a condom?"
Answer: C
Explanation: A) Female rape victims may request information about emergency contraception if the attacker did not use a condom. The nurse should not tell the client that it will be a few more days to know for sure if she is pregnant. The nurse should not question whether the rapist used a condom. The client does not want to get pregnant. The nurse should not talk about giving a baby up for adoption at this time.
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The nurse working in the emergency department is aware that rape victims initially exhibit which emotions? Select all that apply.
A) Shock
B) Disbelief
C) Anger
D) Self-blame
E) Humiliation
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Answer: A, B
Explanation: A) Initial responses to rape generally include feelings of shock and disbelief. Anger, humiliation, and self-blame are early responses but not typically the initial response.
244
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A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted syphilis. Which prescription does the nurse anticipate for this client?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Tinidazole
D) Doxycycline
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Answer: A
Explanation: A) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and either azithromycin or doxycycline. Trichomoniasis is treated with tinidazole or metronidazole. Chlamydia is treated with doxycycline.
245
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A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted trichomoniasis. Which prescription does the nurse anticipate for this client?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Metronidazole
D) Doxycycline
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Answer: C
Explanation: A) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and azithromycin. Chlamydia is treated with doxycycline.
246
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Which type of rape often involves the use of date rape drugs?
A) Acquaintance rape
B) Marital rape
C) Anal rape
D) Gang rape
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Answer: A
Explanation: A) The most common type of rape that uses date rape drugs is acquaintance rape, which is rape committed by an acquaintance or other familiar individual. Although the other types of rape may involve date rape drugs, this is far less common than for acquaintance rape.
247
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The nurse is caring for a client who has a history of being physically and sexually abused as a child, and his father abandoned the family when he was 7 years old. The nurse recognizes that this increases the client's risk of becoming a perpetrator of rape because of which type of risk factors?
A) Individual
B) Relationship
C) Community
D) Societal
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Explanation: A) Relationship risk factors for perpetration include a family environment characterized by physical violence and conflict; a childhood history of physical, sexual, or emotional abuse; and poor parent-child relationships, particularly with fathers. Although the client may also have individual, community, or societal risk factors as well, the factors the nurse has identified here are relationship risk factors.
248
A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client's plan of care before discharge?
A) Help the client find a new long-term care facility.
B) Help the client create a post-discharge safety plan.
C) Help the client find a lawyer to sue the long-term care facility.
D) Help the client understand the warning signs of suicide.
A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client's plan of care before discharge?
A) Help the client find a new long-term care facility.
B) Help the client create a post-discharge safety plan.
C) Help the client find a lawyer to sue the long-term care facility.
D) Help the client understand the warning signs of suicide.
249
The nurse is preparing to teach a class about date rape to a group of college-age students. When discussing date rape drugs, which method of prevention should the nurse include in her presentation?
A) Never leave a location with a friend.
B) Only accept premade drinks from someone you know.
C) Never leave your drink unattended.
D) Only consume drinks handed to you directly by the bartender or a waitress.
Answer: C
Explanation: A) The nurse should include several methods of prevention in her presentation, including the instruction to never leave your drink unattended. Individuals are often given date rape drugs by acquaintances, so accepting premade drinks even from an acquaintance may not be safe. Individuals should watch their drink being made by the bartender rather than trusting that all drinks coming directly from a bartender or waitress are safe. Individuals may leave a location with a friend that they explicitly trust even if they feel they have been drugged.
250
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client?
A) Dependent function of nursing that needs a healthcare provider's order to implement
B) Important independent nursing function
C) Activity nurses begin to learn after training on the job
D) Way to establish the client's dependence on the nurse
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client?
A) Dependent function of nursing that needs a healthcare provider's order to implement
B) Important independent nursing function
C) Activity nurses begin to learn after training on the job
D) Way to establish the client's dependence on the nurse
251
The nurse is caring for an adult client who has been diagnosed with high cholesterol. Which is important for the nurse to consider when teaching this adult client?
A) Adults are more oriented to learning when the material is useful immediately.
B) Adults are more likely to adhere to a regimen than are children.
C) Adults usually can find information on their own.
D) Adults do not need to be evaluated for understanding as children do.
Answer: A
Explanation: A) When teaching a client, the nurse considers that most people learn and retain information if the information is immediately useful. Some clients can find information on their own; however, not all information that the client can find is factual, and clients should be taught how to discern the difference between trustworthy information and unreliable and potentially dangerous information. All clients need to be evaluated to ensure that the right information was retained. Adults will not necessarily adhere to a regimen more than children will. Effective teaching and the client's readiness to learn help with adherence.
252
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Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations?
A) Constructivist
B) Behaviorist
C) Social learning
D) Cognitive
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Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations?
A) Constructivist
B) Behaviorist
C) Social learning
D) CognitiveAnswer: A
Explanation: A) Constructivist theory holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations. In behaviorist theory, learning is thought to occur when an individual's response to a stimulus is either positively or negatively reinforced. In social learning theory, learning primarily results from instruction and observation. In cognitive learning theory, learning involves the processes of acquiring,
253
A nurse is working in a neonatal intensive care unit (NICU). The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn?
A) "You'll give us written instructions before we go home, correct?"
B) "When my baby is just a little bigger, I'll feel more comfortable giving him a bath."
C) "I want to make sure my husband is here, in case I don't hear everything that's said."
D) "I'm so afraid I'll hurt my baby with all these tubes and wires."
Answer: C
Explanation: A) Readiness to learn is the demonstration of behaviors or cues that reflect a learner's motivation, desire, and ability to learn at a specific time. The client who wants her husband involved is demonstrating motivation and willingness to learn. Statements about fear of the situation need to be addressed so that the fear will not inhibit the learning process. Wanting to wait until discharge or at least until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur.
254
A nursing student has been assigned to present a teaching project to the class, using each of Bloom's taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply.
A) Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.
B) Class members must list the technical skills they have learned.
C) Class members must demonstrate a favorite nursing skill for the class.
D) Class members must reflect on how they felt the first time they provided direct client care.
E) Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.
Answer: D, E
Explanation: A) In cognitive theory, learning occurs across three primary domains: cognitive, or "thinking"; affective, or "feeling"; and psychomotor, or "skill." The affective domain includes emotional responses to tasks, such as feelings, emotions, interests, attitudes, and appreciations. Listing technical skills and reading or summarizing information is part of the cognitive domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation. The psychomotor domain includes hands-on motor skills, such as demonstration.
255
A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn?
A) A client who has been there the longest and is a great "coach" for newcomers
B) A client who has been struggling with following nursing directives regarding discharge goals
C) A client who is excited to learn ambulation techniques
D) The client who has just moved in and is already eager for discharge
Answer: C
Explanation: A) Motivation is the desire to learn and influences how quickly and to what extent an individual learns. It is generally greatest when an individual recognizes a need and believes the need will be met through learning. The client who is excited to learn about ambulation techniques understands that learning about it will help take his recovery to a high level.
256
The nurse educator is preparing to teach a group of nursing students how to navigate the internet to research healthcare information. Which does the educator plan to include during lecture?
A) A directory of campus internet sites of interest
B) How to search for and evaluate health information
C) A directory of libraries
D) Information technology instruction
Answer: B
Explanation: A) Campus health centers that use the internet as a tool for health education must train nursing students regarding how to search for and evaluate the health information they find. Sites of interest for the campus would not directly impact the nursing program. Information technology is a subject that teaches nurses how to use technology for the delivery of care and communication. Libraries are important, but knowing about them would not be a part of this presentation.
257
The nurse provides medication teaching for a client who will be going home on new medications. Which statement by the client best illustrates compliance with the medication plan?
A) "I think you should have waited until I was ready to go home. Maybe I'd remember better."
B) "I'm glad to know about my new medications. It makes taking them all a lot easier."
C) "If I take my medications as prescribed, I'll feel better."
D) "I already knew most of what you told me."
Answer: B
Explanation: A) Compliance is best illustrated when the individual recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they are prescribed and improves the possibility for following the prescribed regimen. Statements of prior knowledge do not necessarily lead to compliance, and neither does merely restating the advice of the healthcare provider.
258
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The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the
A) client's room.
B) pediatric ward waiting area.
C) hospital cafeteria.
D) pediatric ward play area.
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Answer: A
Explanation: A) Be sure all teaching interventions are implemented in a safe environment using a calm approach, and take care to address any concerns or fears of the child or parent/caregiver. In this client's case, the waiting or play areas for the pediatric ward are likely to be busy places and brightly lit. The cafeteria is also likely to be too loud and bright. The client's room, where the nurse can control to a greater degree the amount of light and noise, is best for teaching this client.
259
Answer: A
Explanation: A) Be sure all teaching interventions are implemented in a safe environment using a calm approach, and take care to address any concerns or fears of the child or parent/caregiver. In this client's case, the waiting or play areas for the pediatric ward are likely to be busy places and brightly lit. The cafeteria is also likely to be too loud and bright. The client's room, where the nurse can control to a greater degree the amount of light and noise, is best for teaching this client.
Answer: A
Explanation: A) The client who refuses to read instructions may not be able to read. The nurse should assess the client's ability to read to ensure proper treatment and to evaluate the client's understanding of the information. It is unlikely that the client does not want the information. The client said that he'd read the instructions later, and so is not opposed to written information. Although the nurse did provide verbal instruction, often clients forget portions because of the amount of information presented at discharge. The client may be ready to learn, but the client's inability to read may be masking that fact.
260
Answer: A
Explanation: A) The client who refuses to read instructions may not be able to read. The nurse should assess the client's ability to read to ensure proper treatment and to evaluate the client's understanding of the information. It is unlikely that the client does not want the information. The client said that he'd read the instructions later, and so is not opposed to written information. Although the nurse did provide verbal instruction, often clients forget portions because of the amount of information presented at discharge. The client may be ready to learn, but the client's inability to read may be masking that fact.
Answer: A
Explanation: A) All of these nursing diagnoses are appropriate for the client who is experiencing chronic obstructive pulmonary disease, but the priority for the nurse to address is impaired gas exchange. If the client's oxygen level is too low, or the carbon dioxide level is too high, the client's life may be threatened. This client will also experience activity intolerance, anxiety, and, at times, ineffective breathing patterns, but the priority diagnosis is Impaired Gas Exchange.
261
The nursing student is planning an educational program for a school project. The program is focusing on cancer detection education for a community group. What should the nursing student plan to include in order to address the various learning styles of the target group?
A) A lecture using many examples for each learning need
B) Multicolored brochures with bright colors
C) A game board with client matching terms
D) Audiovisuals, examples, group discussions, and activities
Answer: D
Explanation: A) When teaching a group, use strategies to address visual, auditory, manipulative, group, and problem-solving types of learners. Using different techniques and a variety of activities is a good way to match the various learning styles of group participants. Multicolored brochures would only address those learners who learn in the visual mode. Lecture may not meet the needs of the entire group. Games are a useful teaching tool but not necessarily useful when addressing a large group of individuals with varying learning styles.
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The nurse is caring for a client who has recently received a permanent colostomy. The client will be going home in several days and requires discharge teaching. What should the nurse do when organizing the teaching experience?
A) Ask the client to tell the nurse what he knows about caring for the colostomy.
B) Make sure the client's spouse is present before the teaching session begins.
C) Start from the beginning and proceed through all steps required to perform colostomy care.
D) Break the information into small sessions to enhance learning.
Answer: A
Explanation: A) The nurse should find out what the client knows, and then proceed to the unknown. This gives the client confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form. Going over information already learned is not practicing good time management for the nurse or the client. Unless the client has attention problems or is an older adult, breaking up the sessions is probably unnecessary. Having the spouse present is always a good idea, but finding out what the client already knows is more important when organizing teaching.
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A community health nurse runs a clinic that provides health screening mainly to Mexican American and Filipino American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. What action should the nurse take to adjust to their time orientation?
A) Organize the instructions around short-term objectives.
B) Mail letters ahead of time to make sure clients are informed about the upcoming class.
C) Make posters and place them in areas of the community frequented by these groups.
D) Make sure that the classes are held at specific times.
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Answer: A
Explanation: A) Cultures with a predominant orientation to the present include the Mexican American, Navajo Native American, Appalachian, Eskimo, and Filipino American cultures. Preventing future problems may be less significant for these clients than for others, so teaching prevention may be more difficult. In such instances, the nurse can emphasize preventing short-term problems rather than long-term problems. Schedules have to be very flexible in present-oriented societies. Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective. The nurse must be quite flexible, treat the culture's beliefs with respect, and not expect that cultural practices will change to reflect the nurse's needs.
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A nurse is providing a series of educational workshops for caregivers of older clients interested in promoting the health and well-being of their clients. Which would be appropriate topics for this group? Select all that apply.
A) Fall prevention
B) Medication use and side effects
C) Safe driving evaluations
D) Advance directives
E) Responsible sexual behavior
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Answer: A, B, C, D
Explanation: A) It is important for caregivers of older clients to learn about how to prevent falls, medication use and side effects, safe driving evaluations, and advance directives, but it would be much less appropriate for this age group to include teaching about responsible sexual behavior, which would be better addressed to younger adult clients.
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The nurse is caring for a client with a new tracheostomy. After completing a teaching session on tracheostomy care, what should the nurse include in the documentation?
A) The language used for teaching
B) The need for additional teaching
C) The client's questions after the teaching session
D) The supplies required for teaching
Answer: B
Explanation: A) The parts of the teaching process that should be documented in the client's chart include the need for additional teaching. Documenting the client's language is not necessary as it should already be in the nursing history. Supplies required for teaching are not documented. The client's questions are not documented, but the client's understanding at the end of the session is documented.
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A nurse is caring for a child who is hospitalized for an exacerbation of asthma. The nurse is preparing discharge teaching, as the client will be going home on nebulizer treatments and an inhaler. The client and her family members, who are recent immigrants to the United States, speak little English. In addition to enlisting an interpreter to help with the language barrier, what should be a priority for the nurse in developing a teaching plan?
A) Provide written instructions before discharge.
B) Make sure the parents can set up the treatments for their child.
C) Make sure the child comes back for the follow-up appointment.
D) Address any healing beliefs the family has.
Answer: D
Explanation: A) Providing an interpreter to assist with communication is extremely important in this situation. However, if the prescribed treatment conflicts with the client/family's cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client's parents. It is also important to provide written material and assess the psychomotor skills of the child, but the first priority is ascertaining any belief conflicts that may interfere with the treatment and cause the parents to resist the prescribed treatment or bringing the child back for a follow-up appointment.
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The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to independently perform fingerstick blood sugar analysis as part of the plan of care. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." Which is the best action by the nurse based on the client's statement?
A) Document that the client understands teaching.
B) Teach the client's support system how to perform the procedure.
C) Give the client printed learning materials.
D) Watch the client perform a return demonstration of the skill.
Answer: D
Explanation: A) The nurse is responsible for documenting that the client can perform the skill that has been taught. Giving the client written directions or teaching the support individual does not meet the requirement that the client will perform the skill. The nurse cannot document that the client understands teaching until a return demonstration by the client is correctly performed.
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What is a good way for a nurse to prepare the environment for teaching?
A) Keep to a strict schedule decided in advance.
B) Emphasize the importance of paying close attention if client reactions demonstrate confusion.
C) Evaluate client abilities to perform skills with return demonstrations.
D) Inform students that they need to take effective notes because you will not be repeating
Answer: C
Explanation: A) Return demonstrations are an effective way to evaluate whether clients are able to perform newly learned skills, and they contribute to a good environment for teaching. Nurses should take time for teaching, not simply adhere to strictly predefined schedules. Nurses must be able to adapt teaching based on client reactions, and they should be prepared to repeat instructions.
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A home health nurse is admitting a new client to the agency who was recently discharged from the hospital with a new diagnosis of pulmonary fibrosis. What is the best way for the nurse to evaluate whether the client is able to set up and administer a nebulizer treatment?
A) Direct observation of behavior
B) Written description by the client of the treatment
C) Oral description by the client of the treatment
D) The client reports success or failure with the treatment at a follow-up appointment
Answer: A
Explanation: A) The best way for the nurse to evaluate whether this client is able to set up and administer a nebulizer treatment is by direct observation of the client doing it. A written or oral description of the treatment does not as directly demonstrate that the client can set it up and administer it, and the client reporting success or failure at a follow-up visit doesn't give the nurse a direct means of evaluating what the client understands.
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The nurse is conducting a class for a group of pregnant clients and wants to focus specifically on the risks of alcohol consumption for the developing fetus. Which topic should the nurse include with regard to safety of the fetus?
A) Human growth and development
B) Nutrition
C) Lifestyle modification
D) Stress management
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Answer: C
Explanation: A) The nurse should focus on lifestyle modification if she plans to focus specifically on the risks of alcohol consumption for the developing fetus. Human growth and development, nutrition, and stress management are all worthwhile topics for these clients, but none of them as directly address the risks of alcohol consumption.
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Answer: C
Explanation: A) The nurse should focus on lifestyle modification if she plans to focus specifically on the risks of alcohol consumption for the developing fetus. Human growth and development, nutrition, and stress management are all worthwhile topics for these clients, but none of them as directly address the risks of alcohol consumption.
Answer: A
Explanation: A) During the physical examination, the nurse may use findings to evaluate learning needs. In this client's case, verbal instructions are fine to use if the client is in a position to see the nurse's lips move. Written instructions, visual media, and physical demonstrations also might be useful for this client when indicated, but not exclusively.
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Answer: A
Explanation: A) During the physical examination, the nurse may use findings to evaluate learning needs. In this client's case, verbal instructions are fine to use if the client is in a position to see the nurse's lips move. Written instructions, visual media, and physical demonstrations also might be useful for this client when indicated, but not exclusively.
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Answer: D
Explanation: A) The client did not implement what he was taught in class given the evidence of fall hazards the class specifically addressed. The nurse should document the learning outcome as noncompliance. The client might not have heard necessary information during the class because of a hearing deficit or being distracted, the client might not have understood the information because of the way it was presented or for some other reason, or the client may have chosen not to comply with the teaching, but the nurse cannot know which of these might be the case, if any, without further evaluation of the client.
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) The nurse is planning discharge teaching to a client with diabetes who has a large wound. Which is the priority action for the nurse prior to initiating teaching with this client?
A) Asking the client to state what is known about the current dressing changes
B) Teaching the client how to take blood sugars
C) Assessing the client's ability to self-administer insulin
D) Determining the client's reaction to having diabetes
Answer: A
Explanation: A) Nurses need to provide client education that will ensure the client's safe transition from one level of care to another and make appropriate plans for follow-up education in the client's home. Discharge plans must include information about what the client has been taught before transfer or discharge and what remains for the client to learn to perform self-care in the home or other residence.
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) The nurse asks the client to repeat the information taught during the discharge teaching session. The client states, "I have forgotten everything you just said." Which action by the nurse would is appropriate at this time?
A) Repeating the information and having the client write it down as the nurse teaches
B) Having the client wait to ask questions until after the presentation
C) Assigning another nurse to provide the teaching for the client
D) Asking the client their preferred learning strategies
Answer: A
Explanation: A) It is important for nurses to evaluate their own teaching and the content of the teaching program, just as they evaluate the effectiveness of nursing interventions for other nursing diagnoses. The nurse should not feel ineffective as a teacher if the client forgets some of what is taught. Forgetting is normal and should be anticipated. Having the client write down information, repeating it during teaching, giving handouts on the information, and having the client be active in the learning process all promote retention.
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A menopausal client is concerned that intercourse with her spouse has become increasingly painful. What should the nurse explain about the changes in this client's body after menopause?
A) Cervical mucus is thicker.
B) Estrogen levels increase.
C) Sexual desire diminishes.
D) Vaginal lubrication decreases.
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Answer: D
Explanation: A) Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. However, vaginal lubrication and elasticity decrease with menopause and the accompanying decline in estrogen, and this can lead to painful intercourse. The client's concerns are not related to cervical mucus.
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A female client tells the nurse she is having difficulty with sexual relations because of a recent weight gain. When planning this client's care, the nurse should prioritize interventions related to which of the following areas?
A) Sexual self-concept
B) Gender identity
C) Body image
D) Gender-role behavior
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Answer: C
Explanation: A) An individual's body image is constantly changing. How people feel about their bodies is related to sexuality, and people who have a poor body image may respond negatively to sexual arousal. This is what the client is experiencing. Sexual self-concept determines the gender and kinds of individuals to whom the person is attracted; the individual's values about when, where, how, and with whom he or she expresses his or her sexuality; and the individual's ability to freely choose sexual partners. Gender identity refers to an individual's self-image as a male, female, or transgender person. Gender-role behavior is the outward expression of an individual's sense of maleness or femaleness, as well as the expression of what is perceived as gender-appropriate behavior
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Which of the following statements is true with regard to human sexuality?
A) The term "intersex" is used to describe individuals whose gender identity and/or gender expression differs from the gender they were assigned at birth.
B) Members of the medical and psychological professions believe that all transgender individuals are affected by gender dysphoria.
C) Today, the terms "transgender" and "transsexual" are typically used interchangeably.
D) Transgender individuals are at increased risk for violence, discrimination, poverty, and limited access to healthcare.
Answer: D
Explanation: A) Intersex individuals are people who have contradictions among their chromosomal gender, gonadal gender, internal sex organs, and external genital appearance, whereas transgender individuals are people whose gender identity and/or expression differs from the gender they were assigned at birth. In the past, transgender individuals were often referred to as transsexual, although use of this term is now usually limited to people who have changed or seek to change their sexual anatomy through medical interventions. Some–but not all–transgender individuals are affected by a condition called gender dysphoria, which involves strong and persistent feelings of discomfort with one's assigned gender. Regardless of terminology and diagnoses, all transgender individuals are at increased risk for violence, discrimination, poverty, and limited access to healthcare.
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During a health history, the nurse learns that a male client has a recent onset of erectile dysfunction (ED). Which assessment question is likely to elicit the most useful information about factors that may be contributing to the client's ED?
A) "Does this occur often?"
B) "For what diseases and disorders have you been treated?"
C) "Are you on any medications?"
D) "How does your partner feel about this problem?"
Answer: B
Explanation: A) The client's health history can provide clues regarding the underlying cause of the erectile dysfunction (ED). The question "For what diseases and disorders have you been treated?" would most likely provide useful information as to possible causes for the recent onset of the disorder. Asking the client whether ED occurs often will not help identify the cause of the problem, nor will asking the client how his partner feels about the situation. Inquiring about the client's medication use would be useful; however, the inquiry should be phrased as an open-ended question and not a closed-ended question, as it is here.
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Answer: B
Explanation: A) The client's health history can provide clues regarding the underlying cause of the erectile dysfunction (ED). The question "For what diseases and disorders have you been treated?" would most likely provide useful information as to possible causes for the recent onset of the disorder. Asking the client whether ED occurs often will not help identify the cause of the problem, nor will asking the client how his partner feels about the situation. Inquiring about the client's medication use would be useful; however, the inquiry should be phrased as an open-ended question and not a closed-ended question, as it is here.
Answer: B, E
Explanation: A) The client is complaining of a strange discharge from her vagina, which may beindicative of infection. A Papanicolaou test would therefore be useful because it can diagnose certain types of infection. The client is also complaining of stinging with urination, so a urine culture would be helpful to rule out a urinary tract infection as the cause of the urinary pain. This client's symptoms are not associated with pregnancy, so a pregnancy test would not be useful. The remaining diagnostic tests listed here may or may not help diagnose this client's health problem.
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A community health nurse is educating a group of teenage girls about the prevention of dating violence. Which statement should the nurse include in teaching?
A) "Studies suggest that males who monitor their partners' whereabouts are less likely to engage in violence than males who do not keep tabs on their partners."
B) "Females can reduce their risk of becoming victims of violence by adopting a submissive role in the dating relationship."
C) "Males who own weapons are no more likely to perpetrate dating violence than males who don't have access to weapons."
D) "Males with a history of aggressive behavior are more likely to behave violently toward their partners."
Answer: D
Explanation: A) Early warning signs that a male is at risk of perpetrating dating violence include jealous and possessive behaviors (such as monitoring a partner's whereabouts); ownership of weapons; and a history of aggressive behavior. Men who believe that women should be submissive are also more likely to engage in dating violence, even if their partners behave submissively. Encouraging women to act submissively thus not only places them at greater risk of violence, but erodes their sense of agency and self-worth.
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An older adult client tells the nurse that he still has erections and wants to have sex with his wife, but she does not have the same interest in sexual activity as he does. What should the nurse do to assist this client?
A) Explain that women lose interest in sex as part of the aging process.
B) Suggest that the client wait a while and his urge to have sex will pass.
C) Ask what the client has been doing to fulfill himself sexually.
D) Encourage the client to ask his wife to discuss her lack of interest in sexual activity with her healthcare provider.
Answer: D
Explanation: A) Lack of interest in sex is not a normal part of the aging process and suggests that the client's wife is experiencing sexual dysfunction. Thus, the nurse's most appropriate course of action would be to encourage the client to ask his wife to discuss the lack of interest with her healthcare provider as a starting point. The other choices are inappropriate and should not be provided to the client
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A female client is prescribed an androgen medication to treat an estrogen-sensitive type of breast cancer. What should the nurse instruct the client about this medication? Select all that apply.
A) This medication is associated with an increased risk of multiple births.
B) Secondary male sex characteristics may develop from use of this medication.
C) Monitor your weight on a weekly basis when using this medication.
D) When taking this medication, immediately report any calf pain or dyspnea to your healthcare provider.
E) This medication must be taken with food.
Answer: B, C
Explanation: A) Androgen hormone replacements may be used to treat estrogen-dependent cancers. The nurse should instruct female clients about the risk of developing secondary male sex characteristics when taking this type of medication. Androgen medications also affect body weight, so the nurse should instruct the client to monitor her weight on a weekly basis. Increased risk of multiple births is associated with female infertility medications, and increased risk of calf pain or dyspnea is associated with estrogen hormone replacement therapy. Also, androgen medications do not need to be taken with food.
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During a vaginal examination, a woman's cervix and vaginal fornices are found to have a bluish cast to them. This finding suggests that the client
A) is experiencing menopause.
B) may be pregnant.
C) has a pelvic infection.
D) is likely anemic.
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Answer: B
Explanation: A) A bluish color to the cervix and vaginal fornices may be a sign of pregnancy. A pale cervix would be suggestive of anemia. In some women, menopause may cause the vaginal mucosa to become pale and dry, but it would not result in bluish coloration. Similarly, pelvic infection is unlikely to cause the cervix or vaginal mucosa to take on a bluish tint.
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) ________ is a form of sex therapy that involves several stages of guided touching in which clients and their partners are encouraged to explore each other's bodies.
A) Progressive desensitization
B) Integrated therapy
C) Sensate focus
D) Directed masturbation
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Answer: C
Explanation: A) Sensate focus is a type of sex therapy that involves several stages of guided touching. With this method, clients and their partners are encouraged to explore each other's bodies, beginning with areas other than the breasts and genitals, then gradually incorporating these areas as they progress to full intercourse. Directed masturbation is a similar technique, although it is used by clients who do not wish to have a partner participate in the therapeutic process. Integrated sex therapy is a method that involves whatever combination of medical, behavioral, and cognitive techniques the provider(s) determine will be most beneficial to a client's particular problem. Finally, progressive desensitization is not a type of sex therapy.
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Why is type 2 diabetes associated with an increased risk of sexual dysfunction in older adults?
A) Type 2 diabetes causes a decrease in sex hormone levels that may lead to diminished sexual function.
B) Type 2 diabetes contributes to arthritis and other joint problems that can make sexual activity difficult.
C) Type 2 diabetes brings about changes in cellular metabolism that may result in atrophy of the male and female reproductive organs.
D) Type 2 diabetes leads to vascular and nerve damage that may negatively affect sexual function.
Answer: D
Explanation: A) Type 2 diabetes can cause both vascular damage and nerve damage that negatively affect sexual arousal and orgasm. Although decreased sex hormone levels, arthritis, and joint pain can contribute to sexual dysfunction in older adults, these conditions are not related to type 2 diabetes.Furthermore, type 2 diabetes does not contribute to atrophy of the reproductive organs.
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A nurse educator is teaching a group of student nurses about problems of infertility and genetic inheritance of disease. Which statement made by a student nurse indicates that teaching has been effective?
A) "A person's genotype is the observable expression of his or her traits."
B) "The total genetic makeup of an individual is referred to as the phenotype."
C) "In an autosomal recessive inherited disorder, the individual must have two abnormal genes to be affected."
D) "An individual is said to have an autosomal dominant inherited disorder if the disease trait is homozygous."
Answer: C
Explanation: A) In an autosomal recessive inherited disorder, the individual must have two abnormal genes to be affected. A person's phenotype is the observable expression of his or her traits, and the person's genotype is his or her total genetic makeup. An individual is said to have an autosomal dominant inherited disorder if the disease trait is heterozygous—that is, the abnormal gene overshadows the normal gene of the pair to produce the trait.
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A nurse is caring for a client who wants more information about fertility awareness-based contraceptive methods. Which statement made by the nurse provides the client with correct information?
A) "For women, the fertility window occurs between days 19 and 26 of the menstrual cycle."
B) "The calendar rhythm method is based on the assumption that ovulation tends to occur about 7 days before the start of a woman's next menstrual period."
C) "To use the calendar rhythm method, a woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles."
D) "The calendar method is the most reliable fertility awareness-based method of contraception."
Answer: C
Explanation: A) Fertility awareness-based methods, also known as natural family planning, are based on an understanding of the changes that occur throughout a woman's ovulatory cycle. For women, the fertility window occurs between days 8 and 19 of 26- to 32-day cycles. The calendar rhythm method, also called the standard days method, is based on the assumption that ovulation tends to occur about 14 days before the start of a woman's next menstrual period. To use this method, the woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles. The calendar method is the least reliable of the fertility awareness methods.
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A female client tells the nurse she would like to wait to start a family, even though her partner seems interested in having children in the near future. The client then asks the nurse what she should do. Which response from the nurse is best?
A) "Maybe you should babysit a friend's child for a while to see whether you really want children."
B) "You and your partner need to discuss the decision to start a family."
C) "If you don't want to start a family, then you don't have to."
D) "What would you do if you became pregnant now?"
Answer: B
Explanation: A) Making the decision to have children is the first step a couple makes in the process of conception. Sometimes one individual wishes to have a child but the other does not. In these situations, open discussion is essential to reach a mutually acceptable decision. Telling the client that she does not need to start a family if she doesn't want to ignores the issue of the partner's desire for children. Asking what the client would do if she became pregnant now does not address the client's desire to wait to start a family. Suggesting the client babysit a friend's child would be a strategy to help a person decide if he or she wants to have a family, but it does not address the client and spouse's current issue.
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A female client tells the nurse that she does not want to have children because there is a history of Down syndrome in her family. Which of the following statements should the nurse include in her response to this client?
A) "Down syndrome is the most common genetic defect caused by an extra chromosome."
B) "Babies born with Down syndrome do not live very long."
C) "It is probably best to not give birth to a baby with birth defects."
D) "Down syndrome only occurs in the babies of women who are over age 40."
Answer: A
Explanation: A) Down syndrome is the most common trisomy abnormality seen in children. It is the product of the union of a normal egg or sperm with an egg or sperm that has an extra chromosome. This syndrome can occur at any time in a childbearing client of any age. Although children born with Down syndrome have a variety of physical ailments, advances in medical science have extended their life expectancy. The nurse should not provide an opinion about giving birth to a baby with birth defects
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During an evaluation for infertility, a male client is asked to provide a sperm sample. What information from the client's health history could impact the quality and effectiveness of the client's sperm? Select all that apply.
A) Activity level
B) Smoking
C) Use of over-the-counter analgesics
D) Mumps after adolescence
E) Number of siblings
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Answer: B, C, D
Explanation: A) The quality and effectiveness of sperm is affected by smoking history, use of over-the-counter medications, and experiencing mumps after adolescence. Activity level and number of siblings are not criteria to evaluate the quality and effectiveness of a man's sperm.
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During a health history, the nurse learns that a female client has been trying to conceive for 2 years and does not understand why she cannot become pregnant. Which risk factors for infertility should the nurse assess for in this client? Select all that apply.
A) Amount of alcohol consumed each day
B) Poor nutrition
C) Amount of exercise
D) Employment status
E) History of sexually transmitted infections
Answer: A, B, C, E
Explanation: A) Risk factors for female infertility include excess alcohol consumption, poor diet, athletic training, or being infected with a sexually transmitted infection. Employment status is not a risk factor for female infertility.
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A client is prescribed an oral contraceptive that contains estrogen and progesterone. What information should the nurse include when educating the client about this contraceptive? Select all that apply.
A) The estrogen portion of the contraceptive may cause an increase in appetite and subsequent weight gain.
B) The progesterone portion of the contraceptive may cause headaches and nausea.
C) Breast tenderness may occur when taking oral contraceptives that contain estrogen.
D) Taking an oral contraceptive that contains progesterone can lead to an increase in blood pressure.
E) Acne and oily skin are common side effects of the progesterone component in combined oral contraceptives.
Answer: C, E
Explanation: A) There are a variety of possible side effects when taking oral contraceptives that contain both estrogen and progesterone. The estrogen component of these contraceptives may cause headaches, nausea, breast tenderness, and an increase in blood pressure. The progesterone portion may cause acne, oily skin, an increase in appetite, and weight gain.
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The nurse is teaching a client with infertility about the medication clomiphene (Clomid). Which statement on the part of the client indicates that this teaching has been effective?
A) "This medication increases the amount of gonadotropin-releasing hormone."
B) "This medication leads to increased levels of follicle-stimulating hormone."
C) "This medication stimulates the secretion of luteinizing hormone."
D) "This medication increases my estrogen levels so that I can ovulate."
Answer: C
Explanation: A) Clomiphene (Clomid) stimulates the secretion of luteinizing hormone (LH), resulting in the maturation of more ovarian follicles than would normally occur. Clomiphene (Clomid) does not increase estrogen levels, nor does it stimulate secretion of FSH or gonadotropin-releasing hormone.
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A client tells the nurse she plans to use oral contraceptives for birth control. Given this information, which client behavior would cause the nurse the most concern?
A) The client has several sexual partners.
B) The client is being treated for bipolar disorder.
C) The client smokes a pack of cigarettes each day.
D) The client drinks two glasses of wine per day.
Answer: C
Explanation: A) Smoking while taking oral contraceptives increases the client's risk of developing a thrombolytic disorder. Drinking two glasses of wine a day is not a contraindication to the use of oral contraceptives, nor is being treated for bipolar disorder. Having several sexual partners does not preclude the use of oral contraceptives, but the client should be advised that oral contraceptives do not provide protection against sexually transmitted infections so use of a barrier method is also recommended
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) A client wants to use the vaginal sponge as a method of contraception. Which statements indicate that the client needs further instruction about use of this method? Select all that apply.
A) "I should never leave the sponge in for more than 6 hours."
B) "I need to use a lubricant prior to insertion of the sponge."
C) "I can insert the sponge up to 24 hours before having sex."
D) "I need to add spermicidal cream to the sponge prior to having sex."
E) "I need to moisten the sponge with water prior to use."
Answer: A, B, D
Explanation: A) A lubricant is not needed, because the sponge is moistened with water prior to insertion. Spermicidal cream is also unnecessary, because it is already in the sponge. To activate this spermicide, the vaginal sponge must be moistened thoroughly with water. After insertion, the sponge can remain in place for up to 24 hours.
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) Which of the following statements is true with regard to women's sexual health during the postpartum period?
A) The lactational amenorrhea method is the most reliable form of contraception during the postpartum period, but only if a woman is breastfeeding exclusively.
B) Condoms and spermicides should not be used for contraception in the immediate postpartum period, because they increase a woman's risk for uterine infection.
C) Hormonal contraceptives can affect the quantity and quality of breast milk and increase the risk for deep vein thrombosis (DVT) if used in the first month after giving birth.
D) Women who use diaphragms as their primary means of contraception should be refitted for these devices no more than 6 weeks after giving birth.
Answer: C
Explanation: A) Clients who are breastfeeding exclusively may choose the lactational amenorrhea method (LAM). However, the effectiveness of LAM varies greatly, so women who use this method should be encouraged to consider a secondary method of contraception. Condoms and spermicides are an excellent and safe option in the immediate postpartum period. Hormonal contraceptives may be inappropriate because they can affect the quantity and quality of breast milk and increase the risk for DVT if used in the first month after giving birth. Diaphragms should not be used until at least 6 weeks postpartum, at which time the woman will need to be refitted for a new device.
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Why would a healthcare provider most likely recommend that a 37-year-old pregnant woman seek prenatal genetic testing?
A) Because women over age 35 are at increased risk for gestational diabetes and other pregnancy complications
B) Because babies born to women over age 35 are at increased risk for chromosomal abnormalities
C) Because women over age 35 have a higher likelihood of giving birth to twins
D) Because women over age 35 are more likely to give birth to male children
Answer: B
Explanation: A) Genetic testing is recommended for women over age 35 because of the increased risk of giving birth to a child with chromosomal abnormalities. Although women over 35 are at increased risk for pregnancy complications, genetic screening does not reduce this risk. Similarly, while women over age 35 are more likely to have twins, the presence of multiple embryos or fetuses can be determined without the need for genetic testing. Finally, the likelihood of having a male or female child does not vary with maternal age.
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) A nurse is caring for a client who is perimenopausal who states that she has recently had frequent bacterial vaginal infections. Which reason for these infections should the nurse include in the response to the client?
A) Decreased vaginal pH
B) Increased vaginal pH
C) Increased estrogen level
D) Decreased vasomotor stability
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Answer: B
Explanation: A) During perimenopause, vaginal pH increases, predisposing the client to bacterial vaginal infections. Also during perimenopause, estrogen levels decrease, not increase. Although decreased vasomotor stability is characteristic of perimenopause, it leads to hot flashes, not vaginal bacterial infections
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Answer: B
Explanation: A) During perimenopause, vaginal pH increases, predisposing the client to bacterial vaginal infections. Also during perimenopause, estrogen levels decrease, not increase. Although decreased vasomotor stability is characteristic of perimenopause, it leads to hot flashes, not vaginal bacterial infections
Answer: C
Explanation: A) If vaginal dryness and dyspareunia (painful intercourse) are the only symptoms of menopause, then low-dose vaginal estrogen is preferred. Most healthy, recently menopausal women may use HRT for relief of hot flashes and vaginal dryness. Risks for blood clots in the legs and lungs are increased with HRT, but occurrence is rare in women ages 50-59. The risk is further lowered by using low-dose estrogen pills or transdermal patches, gels, or sprays.
300
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A female client asks what causes the symptoms of menopause. On which hormonal function should the nurse focus when responding to this client's question?
A) Increased estradiol levels
B) Increased progesterone levels
C) Decreased estrogen levels
D) Increased luteinizing hormone levels
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Answer: C
Explanation: A) As ovarian function decreases, the production of estrogen decreases, and estradiol is replaced by estrone as the major ovarian estrogen. Estrone is produced in small amounts and has only about one-tenth the biological activity of estradiol. With decreased ovarian function, production of progesterone is also markedly reduced. Although levels of luteinizing hormone increase, they are not the primary cause of the symptoms of menopause.
301
A client with a history of breast cancer who is entering menopause is seeking information about how to manage hot flashes. Which of information should the nurse provide to the client?
A) Soy may be useful in reducing hot flashes, but researchers are still gathering evidence.
B) Hot flashes will continue until menopause is complete.
C) Estrogen is the only reliable treatment for hot flashes.
D) Black cohosh is effective in the management of hot flashes
Answer: A
Explanation: A) Recent research suggests that soy is beneficial in reducing hot flashes during menopause; however, more evidence is needed before soy may be recommended as a treatment alternative. Estrogen is not the only reliable method of treatment for hot flashes, as estrogen/progestin combinations and SERMs have also proven useful in symptom reduction. Black cohosh has been found to be ineffective in managing hot flashes. Advising the client to wait until menopause is complete is inappropriate.
302
The nurse is assessing a postmenopausal client. Which client statement indicates the need for further assessment by the nurse?
A) "I use water-soluble lubricant to treat my vaginal dryness."
B) "For some reason, I have more sexual desire than ever."
C) "Sex certainly takes longer than it used to, but I'm getting used to that."
D) "I am so glad that I don't need to worry about sex anymore."
Answer: D
Explanation: A) The statement "I am so glad that I don't need to worry about sex anymore" merits further assessment by the nurse. This statement is unclear. Does it mean that the client is glad she doesn't have to engage in sex anymore, or does it mean she is happy that she no longer has to worry about getting pregnant? The other statements reflect normal changes associated with aging and healthy responses to those changes.
303
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A premenopausal client tells the nurse that she is not looking forward to menopause because it means her life is over. When the nurse asks what she means by this statement, the client says, "I can't imagine that anyone will have much use for an old woman who can't have children anymore." Based on this statement, which nursing diagnosis would most likely be appropriate for the client at this time?
A) Ineffective Sexuality Pattern
B) Deficient Knowledge
C) Situational Low Self-Esteem
D) Disturbed Body Image
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Answer: C
Explanation: A) The client believes that once she reaches menopause, her life is over. The most appropriate nursing diagnosis for the client at this time would be Situational Low Self-Esteem, because it seems that the client feels that she will no longer have value once she enters menopause; this, in turn, suggests the client has inadequate coping skills to aid with the aging process. There is no information in the client's statement to support the diagnosis of Ineffective Sexuality Pattern. Similarly, based on this statement alone, the client may or may not have deficient knowledge or a disturbed body image.
304
A client who is approaching menopause is interested in oral hormone replacement therapy (HRT) to manage her symptoms. Which of the following points should the nurse include in this client's teaching plans?
A) HRT decreases a woman's risk for deep vein thrombosis.
B) HRT helps protect women against stroke and congestive heart failure.
C) HRT is often useful for women who are at increased risk for osteoporosis.
D) HRT is associated with a reduced incidence of breast cancer and pulmonary embolism.
Answer: C
Explanation: A) Although HRT was once thought to exert cardioprotective effects, several large studies suggest it may actually increase a woman's likelihood of stroke and congestive heart failure. HRT is also associated with increased incidence of deep vein thrombosis, breast cancer, and pulmonary embolism. On the positive side, administration of estrogen has been shown to reduce a woman's risk of developing osteoporosis.
305
A nurse is evaluating the care provided to a client who is experiencing menopause. Which observation indicates that the client is successfully managing her menopausal symptoms?
A) The client has lost 5 pounds in 4 months after starting an exercise program.
B) The client reports consuming about 800 mg of calcium per day.
C) The client has gained 8 pounds in 3 months despite regularly engaging in non-weight-bearing exercise.
Answer: A
Explanation: A) Successful outcomes for a client with menopause include demonstrating a positive sense of self as evidenced by stable weight, participation in a regular exercise program, and ability to manage stress; verbalizing feelings related to changes that have occurred; and describing strategies for maintaining health. Two particularly important health maintenance strategies are engaging in regular weight-bearing exercise and consuming at least 1200 mg of calcium per day, because both of these actions help prevent osteoporosis. Of the options given, only a weight loss of 5 pounds in 4 months after starting an exercise program is evidence of successful management of menopause. The other observations are not evidence of successful management of menopause.
306
A client who is experiencing menopause expresses an interest in using alternative and complementary therapies to manage her symptoms. Which initial response by the nurse is most appropriate?
A) "What types of therapies are of interest to you?"
B) "Those therapies seldom work."
C) "Have you discussed this with your physician?"
D) "Many women report success with these measures."
Answer: A
Explanation: A) Alternative and complementary therapies are used by many women to manage the manifestations associated with menopause. Because the nurse has a responsibility to collect data from the client, the nurse will need to determine which of these therapies are of interest to the client. The success of such remedies varies by user and by therapy. It is inappropriate for the nurse to meet the client's request with negativity. Although clients who use alternative therapies should be asked to report these therapies to their physician, making such a request should not be the nurse's initial step in this scenario.
307
A client who is postmenopausal confides in the nurse that she has been experiencing pain during intercourse. What should the nurse instruct the client to do?
A) Use vaginal lubricants during intercourse.
B) Avoid intercourse.
C) Tolerate this problem because it is a normal part of aging.
D) Decrease the frequency of intercourse to decrease the pain.
Answer: A
Explanation: A) It is not uncommon for postmenopausal females to report painful intercourse related to a decrease in vaginal lubrication. Vaginal lubricants can be very effective in reducing pain during intercourse. Although decreased vaginal lubrication is a normal change of aging, clients do not have to tolerate the associated discomfort. Avoiding sex and decreasing the frequency of intercourse would not resolve this client's problem. Furthermore, it would be stereotypical for the nurse to assume the client has a reduced desire for intercourse because she is postmenopausal.
308
Which of the following clients would be described as experiencing premature ovarian failure?
A) A 29-year-old woman who is receiving chemotherapy that damages her ovaries
B) A 43-year-old woman who has irregular periods as a result of ovarian dysfunction
C) A 35-year-old woman who recently underwent an oophorectomy
D) A 32-year-old woman who does not ovulate because of an abnormally low number of ovarian follicles
Answer: D
Explanation: A) Premature ovarian failure (POF), also known as premature menopause, occurs in women under the age of 40 who do not ovulate each month because of a low number of follicles or ovarian dysfunction. Because of her age, the 43-year-old woman would not be considered to have POF. Similarly, the client undergoing chemotherapy would be experiencing medical menopause, while the client with an oophorectomy would be experiencing surgical menopause.
309
Which of the following statements is true with regard to surgical menopause and oophorectomy?
A) Natural conception is not an option for women who have undergone single oophorectomy.
B) Surgical menopause may be successfully treated with hormone replacement therapy.
C) Onset of surgical menopause is usually gradual.
D) Oophorectomy is always accompanied by either hysterectomy or salpingectomy.
Answer: B
Explanation: A) Oophorectomy may be done alone or may be combined with hysterectomy and/or salpingectomy. Unlike medical menopause, onset of surgical menopause is abrupt. Symptoms may be severe and may be treated with HRT. If oophorectomy involves one ovary, clients may still be able to conceive naturally; natural conception is not an option if oophorectomy involves both ovaries.
310
Which of the following statements is true regarding the etiology and pathophysiology of primary dysmenorrhea?
A) Primary dysmenorrhea is caused by decreased levels of prostaglandins, which cause uterine contractions to increase in strength.
B) Primary dysmenorrhea begins within the first three or four menstrual periods after menarche and will occur with each ovulatory cycle during a woman's teens and twenties.
C) Secondary dysmenorrhea is more common than primary dysmenorrhea.
D) Causes of primary dysmenorrhea include endometriosis, tumors, cysts, pelvic adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and adenomyosis.
Answer: B
Explanation: A) Pain associated with menses, called dysmenorrhea, is one of the most common menstrual dysfunctions. Primary dysmenorrhea is common among women with normal menstrual function and is more common than secondary dysmenorrhea. Primary dysmenorrhea is caused by the release of prostaglandins that cause the contractions of the uterus needed to expel menstrual fluid and tissue. Primary dysmenorrhea begins within the first three or four menstrual periods after menarche and will occur with each ovulatory cycle during a woman's teens and twenties. Secondary dysmenorrhea is related to pathology or diseases that affect the uterus and pelvic area. Causes of secondary dysmenorrhea include endometriosis, tumors, cysts, pelvic adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and adenomyosis.
311
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The nurse is caring for a young adult client who reports that she has painful periods. Which assessment findings suggest that this client is experiencing primary dysmenorrhea? Select all that apply.
A) Bleeding between menstrual periods
B) Headache
C) Fatigue
D) Diarrhea
E) Scant menses
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Answer: B, C, D
Explanation: A) Manifestations of primary dysmenorrhea include headache, diarrhea, fatigue, vomiting, breast tenderness, and pain radiating to the lower back and thighs. Scant menses is a symptom of hormone imbalance. Bleeding between menstrual periods is characteristic of metrorrhagia.
312
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The nurse is caring for a young adult client who reports that she has painful periods. Which assessment findings suggest that this client is experiencing primary dysmenorrhea? Select all that apply.
A) Bleeding between menstrual periods
B) Headache
C) Fatigue
D) Diarrhea
E) Scant menses
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Answer: B, C, D
Explanation: A) Manifestations of primary dysmenorrhea include headache, diarrhea, fatigue, vomiting, breast tenderness, and pain radiating to the lower back and thighs. Scant menses is a symptom of hormone imbalance. Bleeding between menstrual periods is characteristic of metrorrhagia.
313
The nurse is assessing the sexual health of a 20-year-old female client. Which of the following findings should the nurse identify as risk factors for dysfunctional uterine bleeding? Select all that apply.
A) High level of stress
B) Weight gain of 20 pounds in 2 months
C) Use of birth control pills for contraception
D) History of peptic ulcer disease
E) Limited intake of high-fat foods
Answer: A, B, C
Explanation: A) A number of factors may predispose a woman to dysfunctional uterine bleeding. These factors include stress, extreme weight changes, and use of hormonal birth control. Dysfunctional uterine bleeding is usually related to hormonal imbalances and not associated with peptic ulcer disease or low-fat diets.
314
A young adolescent client is concerned about experiencing severe cramps with menstruation. She tells the nurse, "I don't like the pain, and I'm also worried the cramps mean there is something wrong with me." How should the nurse respond to this client?
A) "Menstrual cramping is not normal but is something that can be treated."
B) "You have cramps because you started your periods too early."
C) "Cramps are common in young women who just started having their periods, but they can be managed and often become less severe over time."
D) "You need to see a gynecologist for a pelvic examination."
Answer: C
Explanation: A) Primary dysmenorrhea occurs without specific pelvic pathology and is most often seen in girls who have just begun menstruating, usually becoming less severe after a woman's mid-20s. The client is an early adolescent, so she is in the normal age range to start having periods. Cramps are common in this age range, so the client does not need to see a gynecologist for a pelvic examination. However, the client would benefit from teaching about how to reduce and manage her menstrual pain.
315
The nurse is working with a client who experiences severe premenstrual syndrome. Which of the following interventions should the nurse suggest to assist the client in coping with this disorder?
A) "Take frequent rest periods."
B) "Consider drinking 4 ounces of wine each day."
C) "Be sure to exercise and use relaxation techniques on a regular basis."
D) "Avoid contraception during menstruation when engaging in sexual intercourse."
Answer: C
Explanation: A) Interventions to promote effective coping in a client with severe premenstrual syndrome include encouraging exercise and use of relaxation techniques. Alcohol intake should be avoided, so the client should not be encouraged to have 4 ounces of wine each day. The client should be instructed to use contraception if engaging in sexual intercourse during menstruation because ovulation and pregnancy can occur. Frequent rest periods would be beneficial for a client with dysfunctional uterine bleeding but not a client with premenstrual syndrome.
316
A nurse is preparing to teach a group of young women about strategies for the relief of menstrual cramping. What should be the focus of these strategies?
A) Minimizing menstrual flow
B) Avoiding uterine contraction
C) Increasing blood flow to the uterine muscle
D) Decreasing estrogen production
Answer: C
Explanation: A) Menstrual cramping is a result of muscle ischemia that occurs when the client experiences powerful uterine contractions. Increasing blood flow to the uterine muscle through rest, certain exercises, application of heat to the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease pain and cramping. There is no connection between pain and the actual amount of menstrual flow. Estrogen production should follow normal patterns and should not be altered.
317
The nurse instructs a client on ways to reduce premenstrual difficulty. Which statement on the part of the client indicates that the instruction was beneficial?
A) The client states the need to increase dietary sugar intake to promote energy.
B) The client states that guided imagery does not help with premenstrual symptoms.
C) The client states the need to increase intake of simple carbohydrates.
D) The client states that reducing caffeine intake will help.
Answer: D
Explanation: A) The client stating that a reduction in caffeine intake will help reduce premenstrual difficulty is evidence that the instruction was beneficial. The other client statements all indicate the need for additional instruction, because guided imagery can be used to reduce stress and promote relaxation and intake of simple carbohydrates and sugars should be reduced.
318
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Which of the following interventions should the nurse recommend to a client who is experiencing primary dysmenorrhea? Select all that apply.
A) Increase caffeine intake.
B) Use a heating pad.
C) Try relaxation techniques.
D) Engage in regular exercise.
E) Avoid vitamin supplements.
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Answer: B, C, D
Explanation: A) Regular aerobic activity helps decrease dysmenorrhea symptoms. Caffeine intake should be restricted to reduce irritability. Relaxation techniques may be useful because they promote the release of pain-relieving endorphins. Vitamin supplements should not be avoided and may be needed to help control symptoms. A heating pad can help reduce abdominal cramping and pain.
319
In what way does menometrorrhagia differ from menorrhagia?
A) Menometrorrhagia involves excessive menstruation, whereas menorrhagia does not.
B) Menometrorrhagia involves irregular menstruation, whereas menorrhagia does not.
C) Menometrorrhagia involves prolonged menstruation, whereas menorrhagia does not.
D) Menometrorrhagia involves the absence of menstruation, whereas menorrhagia does not.
Answer: B
Explanation: A) Menorrhagia is excessive or prolonged menstruation that occurs at regular intervals. Menometrorrhagia is irregular, excessive, prolonged menstruation. It is essentially a combination of the heavy bleeding of menorrhagia and the irregularity of metrorrhagia.
320
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________ is the absence of menstruation by age 14 without having undergone other changes associated with puberty or by age 15 with having undergone normal physical changes of puberty.
A) Primary amenorrhea
B) Oligomenorrhea
C) Secondary amenorrhea
D) Metrorrhagia
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Answer: A
Explanation: A) Primary amenorrhea is the absence of menstruation by age 14 without having undergone other changes associated with puberty or by age 15 with having undergone normal physical changes of puberty. Secondary amenorrhea occurs when a previously menstruating woman does not spot or bleed for a period of time that is three times that of her normal cycle length. Oligomenorrhea is light or infrequent menstruation and occurs when cycles are longer than 6-7 weeks. Metrorrhagia is bleeding of variable amount between menstrual periods.
321
A nurse is gathering the health history of a client with erectile dysfunction (ED). Which finding(s) could indicate a possible cause for the client's ED? Select all that apply.
A) Blood pressure of 118/68 mmHg
B) Treatment for type 2 diabetes mellitus for 7 years
C) Body mass index (BMI) of 24.5
D) Alcohol intake of 4 to 6 beers each day
E) Engaging in moderate exercise twice a week
Answer: B, D
Explanation: A) Risk factors for ED are numerous. They include advancing age, diseases such as heart disease and diabetes, trauma, and the use of prescription or illicit drugs. Excessive use of alcohol can also result in erectile dysfunction. Engaging in moderate exercise, a body mass index within normal limits, and normal blood pressure would not provide a possible cause for the client's recent experience with ED.
322
A 30-year-old client is concerned that he will become impotent after experiencing difficulty sustaining an erection during a recent sexual encounter. What is the nurse's best response to this client's concerns?
A) "An occasional incident like this is normal and common."
B) "Sexually transmitted infections may result in sexual problems in adults."
C) "Erectile dysfunction is the correct term for inability to achieve or sustain an erection."
D) "A medical diagnosis of erectile dysfunction is not made until a man has experienced erectile difficulties for a period of at least 3 months."
Answer: A
Explanation: A) This client is concerned that he may become impotent. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties. The other options are also true, but they do not serve to alleviate the client's concerns. If the client continues to have difficulties achieving or sustaining an erection, further investigation is warranted. Simply correcting the client's use of medical terminology does not address his concerns.
323
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A male client tells the nurse that he has no idea why his wife wants to stay married to him because he has not been able to "perform" sexually since his prostate surgery. Based on the client's statement, which nursing diagnosis would be most appropriate?
A) Ineffective Coping
B) Situational Low Self-Esteem
C) Hormonal Imbalance
D) Sexual Dysfunction
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Answer: B
Explanation: A) This statement suggests that the client's inability to "perform" in sexual situations is causing him to question his self-worth. Situational Low Self-Esteem is therefore the most appropriate nursing diagnosis for the client at this time. A diagnosis of Sexual Dysfunction is associated with anxiety concerning the cause of the dysfunction, which is not the case for this client. The information given here is insufficient to determine whether the client is experiencing Ineffective Coping. Finally, Hormonal Imbalance is not a nursing diagnosis.
324
) What should the nurse include in the plan of care for a client experiencing erectile dysfunction due to a chronic health condition? Select all that apply.
A) Information about herbal supplements that can help treat ED
B) Information on prescription medications used in ED treatment
C) Brief description of types of devices and surgeries available to help with ED
D) Explanation of how to discontinue any prescribed medications that may be contributing to the client's ED
E) Information on the exact cause of the client's ED
Answer: B, C
Explanation: A) When planning care for a client with ED related to a chronic health condition, the nurse should include information on medications for treatment and types of devices and surgeries available to help with the disorder. Because an exact cause of the client's ED may be difficult to determine, this information would not be appropriate for the nurse to include in the plan of care. Discussing herbal supplements would also be inappropriate because none of these substances have been found to be effective in the treatment of ED. The nurse should not encourage the client to discontinue any medications that may be causing sexual side effects; rather, the nurse should advise the client to discuss these medications with his provider before stopping treatment or pursuing other medication options.
325
) The nurse is instructing a client about the medication sildenafil (Viagra). Which statement on the part of the client indicates that this teaching has been effective?
A) "Viagra should be taken with food."
B) "I can take Viagra at the same time I take my daily alpha-adrenergic blocker."
C) "I can take only one pill in a 24-hour period."
D) "Viagra works by decreasing blood flow to the penis."
Answer: C
Explanation: A) Sildenafil (Viagra) acts by facilitating relaxation of smooth muscle in the penis, thus allowing increased blood flow. This drug should be taken no more than once per day, should not be used by men who are taking nitrate-based drugs or alpha-adrenergic blockers, and does not need to be taken with food.
326
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The nurse is caring for a client with erectile dysfunction (ED). Which medication(s) should the nurse anticipate being prescribed for this client? Select all that apply.
A) Sildenafil (Viagra)
B) Methylphenidate (Ritalin)
C) Vardenafil (Levitra)
D) Buspirone (BuSpar)
E) Tadalafil (Cialis)
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Answer: A, C, E
Explanation: A) Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are all oral medications that act by facilitating relaxation of smooth muscle in the penis, thus allowing increased blood flow and erection. Buspirone (BuSpar) is an antianxiety agent and is not effective in the treatment of ED. Methylphenidate (Ritalin) is a mild central nervous system stimulant and is not effective for ED.
327
A client asks for a prescription for tadalafil (Cialis). Given this information, what should the nurse ask the client prior to creating a plan of care?
A) "Do you have diabetes mellitus?"
B) "Are you comfortable taking this medication twice per day?"
C) "Do you have any sexually transmitted infections?"
D) "Do you use nitroglycerine?"
Answer: D
Explanation: A) Tadalafil (Cialis) should not be used by clients who are taking nitroglycerine and other nitrate-based drugs. Neither diabetes mellitus nor a sexually transmitted infection is a contraindication to the use of Cialis. Cialis should be taken no more than once per day, so there is no need to ask the client whether he is comfortable taking multiple doses in a 24-hour period.
328
A client reports that he is having difficulty ejaculating during sexual activity, even though he is able to maintain an erection for 30-45 minutes. The client tells the nurse that this problem began about 6 months ago and has been a source of significant worry for both him and his partner. Based on this description, the client is most likely affected by which of the following conditions?
A) Retrograde ejaculation
B) Delayed ejaculation
C) Erectile dysfunction
D) Male hypoactive sexual desire disorder
Answer: B
Explanation: A) Delayed ejaculation, once called male orgasmic disorder, involves extreme difficulty ejaculating, despite the ability to maintain an erection for long periods. Delayed ejaculation is a distinct disorder from retrograde ejaculation, in which ejaculation occurs but the fluid travels into the bladder instead of out through the urethra. Erectile dysfunction is an inability to attain or maintain an erection sufficient to permit mutually satisfactory sexual intercourse with a partner. Male hypoactive sexual desire disorder involves a deficiency in or absence of sexual fantasies and persistently low interest or a total lack of interest in sexual activity.
329
A 45-year-old female client tells the nurse that she has not had any interest in sex for about 8 months. During this time, she has also had difficulty with arousal. Which response by the nurse is best?
A) "Don't worry; all women go through periods where they are uninterested in sex."
B) "It sounds like you might be experiencing female sexual interest/arousal disorder, although your symptoms need to be present for 12 full months before this diagnosis applies."
C) "You are not alone. Lack of interest and arousal is the most common sexual problem reported by female clients."
D) "A lack of interest in sex is a normal consequence of the aging process, and it often begins around the time a woman enters menopause
Answer: C
Explanation: A) Although some declines in desire and arousal are normal with age, a total or near-total lack of interest in sex is not typical and is likely indicative of a larger problem. A diagnosis of female sexual interest/arousal disorder may be appropriate when a woman experiences decreased or absent sexual thoughts, interest in sexual activity, mental or physical feelings of arousal, and/or pleasurable sensation during sexual activity at least 75% of the time for a period of 6 months or more. Female sexual interest/arousal disorder is the most common female sexual dysfunction.
330
) The nurse is planning care for a client with female orgasmic disorder. Which of the following elements would least likely be included in the client's plan of care?
A) Referral to a sex therapist
B) Information on the use of vibrators and other mechanical aids
C) Teaching on how to perform pelvic floor exercises
D) Instruction on how to obtain and use vaginal dilators
Answer: D
Explanation: A) A variety of treatment options may be useful for women affected by female orgasmic disorder, including sex therapy; use of vibrators and other mechanical aids; and instruction regarding exercises that strengthen the pelvic floor. Vaginal dilators are used in the treatment of genito-pelvic pain/penetration disorder, not female orgasmic disorder.
331
The nurse is teaching a client about sexual activity during the pregnancy. Which of the client statements indicate that this teaching has been successful?
A) "The elevated androgen levels that accompany pregnancy might reduce my desire for sex."
B) "It's a good idea to avoid vaginal sex during the last few weeks of pregnancy, so I don't risk hurting the baby."
C) "Sexual dysfunction is uncommon during pregnancy, although many women suffer from low desire during the postpartum period."
D) "Pregnant women are most likely to experience sexual difficulties during the third trimester."
Answer: D
Explanation: A) Between 60% and 70% of women experience sexual dysfunction during pregnancy, and an even higher percentage report difficulties during the postpartum period. Sexual problems during pregnancy often fluctuate by trimester. The third trimester is the time when sexual difficulties are most common. Some of these difficulties are related to the decreased androgen levels of pregnancy, while others involve changes in body size and mechanics, self-esteem, and body image. Although some women fear that penetration will harm the fetus, this is rarely the case.
332
A client who gave birth 10 weeks ago via cesarean section tells the nurse that she is having difficulty resuming sexual relations with her husband. She reports both reduced desire for sex and pain upon penetration. What is the nurse's best response to this client?
A) "Are you breastfeeding? If so, switching to formula will help resolve these issues."
B) "Most women don't report these sorts of problems unless they've delivered vaginally."
C) "These problems are common during the postpartum period and usually resolve with time."
D) "Based on the symptoms you're reporting, I'm concerned you might be experiencing a postpartum mood disorder."
Answer: C
Explanation: A) Both reduced desire and sexual pain are common during the postpartum period, regardless of whether a woman gave birth vaginally or via cesarean section. Typically, these problems resolve within several months. Although the hormonal changes associated with breastfeeding may contribute to sexual difficulties, women should be encouraged to continue breastfeeding for the health of their infant. In addition, even though clients with postpartum mood disorders are at increased risk for sexual dysfunction, such dysfunction is not necessarily indicative of a postpartum mood disorder.
333
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A postmenopausal client says to the nurse, "I've lost interest in sex over the past few months, but that's normal for women my age." Based on the client's statement, which nursing diagnosis would be most appropriate?
A) Situational Low Self-Esteem
B) Readiness for Enhanced Communication
C) Readiness for Enhanced Relationship
D) Deficient Knowledge
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Answer: D
Explanation: A) Although some declines in desire and arousal are normal with age, a total or near-total lack of interest in sex is not typical and is likely indicative of a larger problem. Because the client seems unaware of this fact, a diagnosis of Deficient Knowledge is most likely appropriate. Nothing in the client's statement suggests that she suffers from situational low self-esteem or is having difficulty communicating with her spouse or the healthcare team. Furthermore, nothing in the client's statement indicates that relationship issues are a factor in this situation.
334
A 25-year-old client who is taking fluoxetine (Prozac) to treat depression reports decreased sexual desire since starting the medication. What can the nurse anticipate with regard to changes in the client's pharmacological regimen?
A) Addition of bupropion to the client's drug regimen
B) Immediate discontinuation of fluoxetine therapy
C) Addition of flibanserin to the client's drug regimen
D) Replacement of fluoxetine with paroxetine therapy
Answer: A
Explanation: A) SSRI antidepressants, including both fluoxetine (Prozac) and paroxetine (Paxil), are frequently associated with a range of sexual side effects, including reduced desire. Abrupt discontinuation of these medications is not advisable because it can exacerbate a client's depression. Instead, providers may prescribe the atypical antidepressant bupropion (Wellbutrin) along with SSRI therapy, as bupropion can exert desire-increasing effects. Although flibanserin is the only FDA-approved medication specifically aimed at the treatment of low desire in women, it is rarely prescribed and would not be a provider's first treatment option in this scenario.
335
Which of the following terms describes involuntary tightening of the pelvic muscles that prevents penetration from occurring?
A) Female orgasmic disorder
B) Vaginismus
C) Genito-pelvic pain/penetration disorder
D) Dyspareunia
Answer: B
Explanation: A) In women, vaginismus is involuntary tightening of the pelvic muscles that prevents penetration from occurring. Although often associated with genito-pelvic pain/penetration disorder, it is not necessary for this diagnosis. Dyspareunia is pain experienced by a woman during vaginal penetration. Female orgasmic disorder is the persistent delay or absence of orgasm following a phase of normal sexual excitement.
336
Which of the following terms describes involuntary tightening of the pelvic muscles that prevents penetration from occurring?
A) Female orgasmic disorder
B) Vaginismus
C) Genito-pelvic pain/penetration disorder
D) Dyspareunia
Answer: B
Explanation: A) In women, vaginismus is involuntary tightening of the pelvic muscles that prevents penetration from occurring. Although often associated with genito-pelvic pain/penetration disorder, it is not necessary for this diagnosis. Dyspareunia is pain experienced by a woman during vaginal penetration. Female orgasmic disorder is the persistent delay or absence of orgasm following a phase of normal sexual excitement.
337
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The nurse is conducting a history and physical assessment of a sexually active teenage client. Which findings should the nurse identify as consistent with genital herpes? Select all that apply.
A) Low blood pressure
B) Headache
C) Fever
D) Dysuria
E) Vaginal discharge
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Answer: B, C, D, E
Explanation: A) Manifestations of genital herpes include flulike symptoms (e.g., headache, fever), dysuria, and vaginal discharge. Low blood pressure is not a manifestation of genital herpes.
338
The nurse is assessing a client who presents with an open sore on his penis. Which question by the nurse best elicits additional data related to this finding?
A) "Do you think you have a disease?"
B) "Have you had sexual intercourse recently?"
C) "Are you promiscuous?"
D) "When did you initially notice this open area?"
Answer: D
Explanation: A) It is important that the nurse record the onset of the open area. The remaining questions are all closed and will not elicit much information, although determining the date of the last episode of sexual intercourse might be indicated later if a disease is diagnosed. Asking the client about promiscuity is judgmental.
339
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) A client is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted infection(s) should the nurse prepare the client for testing? Select all that apply.
A) Syphilis
B) HIV
C) Chlamydia
D) Human papillomavirus (HPV)
E) Gonorrhea
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Answer: C, E
Explanation: A) Chlamydia and gonorrhea are both bacterial infections that invade the same target organs, including the cervix and male urethra, and create the manifestations of dysuria, urinary frequency, and discharge. The other sexually transmitted infections listed here target other organs and/or create other manifestations.
340
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A client diagnosed with a sexually transmitted infection reports having "no idea" how the illness was contracted. Which nursing diagnosis would be appropriate for the client at this time?
A) Anxiety
B) Deficient Knowledge
C) Ineffective Coping
D) Sexual Dysfunction
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Answer: B
Explanation: A) The client's statement indicates deficient knowledge regarding the transmission of sexually transmitted infections. There is not enough information provided here to determine whether the diagnoses of sexual dysfunction, ineffective coping, and/or anxiety would also be appropriate for this client.
341
The nurse is planning care for a client with gonorrhea who also has a history of prior sexually transmitted infections (STIs). What is the priority nursing action for this client?
A) Instruction about the need to avoid all future sexual contact
B) A plan for the client to contact sexual partners regarding the diagnosis
C) Recommendation that the client increase fluids and rest
D) Teaching regarding the importance of adequate nutrition
Answer: B
Explanation: A) The client has gonorrhea and a history of sexually transmitted infections. The nurse should therefore encourage the client to develop a plan for contacting sexual partners regarding the diagnosis. Increasing fluids, rest, and nutrition are important, but not as important as contacting sexual partners to protect their health and limit the spread of disease. In addition, the nurse should instruct the client to avoid sexual contact until recovered from the current illness, but not necessarily to avoid all future sexual contact.
342
The nurse is providing education to sexual partners about the importance of treatment for a chlamydia infection. Which client statements indicate this teaching was effective? Select all that apply.
A) "Chlamydia can cause inflammation of the tube that carries urine from the bladder to outside the body."
B) "Severe vaginal itching can be a consequence of chlamydia."
C) "Rashes commonly occur with this disease."
D) "Chlamydia can spread to the uterus and fallopian tubes and result in infertility."
E) "Chlamydia can result in pregnancy complications."
Answer: A, D, E
Explanation: A) In men, chlamydia is a major cause of nongonococcal urethritis. In women, chlamydia cervicitis can ascend and become pelvic inflammatory disease, or infection of the uterus, fallopian tubes, and sometimes ovaries. Pregnant women with an untreated chlamydia infection are at greater risk of developing complications such as miscarriage, premature birth, or stillbirth. Chlamydia does not cause vaginal itching or a rash.
343
A client with genital herpes asks the nurse how to manage pain when urinating and difficulty voiding. Which response by the nurse is correct?
A) "Try to limit your fluid intake. That way, you won't have to void so often."
B) "Pouring room-temperature water over your genitals may make it easier for you to start urinating."
C) "Be sure to keep your genitals as dry as possible. Unnecessary exposure to water can worsen your infection and cause even greater pain upon urination."
D) "Unfortunately, there's nothing you can do to eliminate your discomfort. It won't go away until your current herpes outbreak is over."
Answer: B
Explanation: A) Clients with genital herpes who complain of dysuria and difficulty voiding can be taught to pour water over the genitals to start urination and dilute the urine. Drinking additional fluids also helps dilute the urine and reduce the burning sensation when voiding. The nurse might additionally suggest the use of sitz baths (with tepid water) for 15-30 minutes several times a day. The warm water is soothing and decreases pain from ulcers and an irritated urethral meatus. It facilitates wound healing and facilitates urination.
344
The nurse is planning care to address pain in a client with genital herpes. Which intervention would most be appropriate for this plan of care?
A) Do not submerge lesions in water.
B) Clean lesions two or three times a day with warm water and soap.
C) Dry lesions with a hair dryer turned to the hot setting.
D) Wear tight cotton clothing.
Answer: B
Explanation: A) Measures to reduce the discomfort of herpes lesions include cleansing the lesions two or three times a day with warm water and mild soap. Lesions should be dried using a hair dryer turned to the cool setting, and it is important to wear loose cotton clothing that will not trap moisture. Tepid sitz baths are also useful in decreasing pain from ulcers and an irritated urethral meatus.
345
A public health nurse is educating a group of adults about the incidence and prevalence of sexually transmitted infections (STIs). Which statement should be included?
A) "Males have higher rates of gonorrhea and chlamydia, whereas women have higher rates of syphilis."
B) "Men are disproportionately affected by STIs as compared to women and infants."
C) "Women often experience few early manifestations of infection, which causes them to delay diagnosis and treatment."
D) "The incidence of STIs is highest among young Caucasian females."
Answer: C
Explanation: A) Women often experience few early manifestations of sexually transmitted infection, which can lead to delays in diagnosis and treatment. Women have higher rates of gonorrhea, whereas men have higher rates of chlamydia and syphilis. Women and infants are disproportionately affected by STIs as compared to men.
346
A college student is being treated for chlamydia. What should the nurse teach this student to decrease the risk of transmitting another sexually transmitted infection?
A) Unprotected sex is acceptable if you know the partner well.
B) Latex condoms should be used for all sexual activity.
C) Birth control pills will help decrease the risk of pregnancy and STDs.
D) Condoms should be used with petroleum jelly.
Answer: B
Explanation: A) Latex condoms should be used for all sexual activity to decrease the risk of contracting and/or spreading a sexually transmitted infection. Although birth control pills can decrease the risk of pregnancy, they do not protect against the transmission of sexually transmitted infections. Petroleum jelly can damage a condom, defeating its purpose for safe sex. Unprotected sex should only be considered when both partners have been tested for STIs and the relationship is mutually monogamous.
347
Which of the following statements is true with regard to sexually transmitted infections (STIs) and older adults?
A) Because pregnancy is no longer a concern, older adults may not use condoms, thereby increasing their risk of STIs.
B) Normal age-related changes to the body put older adults at reduced risk of contracting STIs.
C) STIs are rare among older adults because of decreased levels of sexual activity among the members of this population.
D) Healthcare providers should avoid discussing STIs with older clients unless these clients initiate the conversation.
Answer: A
Explanation: A) Older adults are living longer, healthier lives and are engaging in sex more than in previous generations. Along with this increase in sexual activity comes an increase in STIs. Normal age-related changes to the body can put older adults at greater risk of infection. In addition, because pregnancy is no longer a concern, older adults may not use condoms or may use them inconsistently. Many older adults are hesitant to discuss sexual practices with their healthcare providers. Thus, providers play a key role in STI prevention by acknowledging that continuation of sexual activity is a normal part of aging, encouraging clients to talk about their sexual practice, dispelling myths about the risk of infection, and providing information that is relevant to older clients.
348
) Which of the following actions on the part of the nurse is most appropriate when treating an 8-year-old client who is exhibiting the symptoms of a sexually transmitted infection (STI)?
A) Immediately perform a detailed examination and collect relevant specimens
B) Assume that the child acquired the infection during the perinatal period
C) Initiate presumptive treatment of the STI as soon as possible
D) Anticipate the need to follow mandatory reporting guidelines
Answer: D
Explanation: A) In some cases, STIs in young children may be the result of perinatally acquired infections that can persist for 2 to 3 years; however, the general rule is to consider infection evidence of abuse. STI testing should be conducted prior to initiating treatment of children exhibiting STI symptoms in order obtain a reliable diagnosis. It is essential to examine and collect specimens from children in a manner that minimizes trauma to them; thus, examination and collection should be conducted by a clinician with specific experience in the area of child sexual abuse. Because STIs in children are often a result of sexual abuse, and also because public health authorities require the reporting of certain STIs, the nurse should anticipate the need to follow mandatory reporting guidelines.
349
The nurse is caring for a client who sustained multiple injuries in an automobile accident. As a part of secondary prevention for this client, which does the nurse include in the plan of care?
A) Promote wellness.
B) Detect early disease.
C) Restore the client to previous functioning.
D) Prevent the progression of more symptoms.
Answer: D
Explanation: A) Rehabilitation is tertiary prevention and is aimed at restoring the client to the previous level of functioning. Prevention of the progression of symptoms and early detection of disease are secondary preventions. Promoting wellness is considered primary prevention.
350
A nurse educator is teaching a group of students about managed care. The educator knows that the students have understood the concept when they state that managed care has which emphasis? Select all that apply.
A) Bringing services of multiple providers to the client
B) Organizing healthcare services around the stated needs of the client
C) Cost-effective care
D) Preventive services
E) Health promotion
Answer: C, D, E
Explanation: A) Managed care describes a healthcare system that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Managed care clinics will emphasize cost-effective care by offering preventive services and health promotion activities. Case management describes a range of models for integrating and delivering healthcare services from multiple providers to the client. Client-focused care is a delivery model that organizes healthcare services around the stated needs of the client.
351
A nurse working on a medical-surgical unit has opted to return to school to earn a Bachelor of Science in Nursing (BSN) degree. After considering projected changes in healthcare and the population cared for in the community, which includes an expanding minority population composed largely of immigrants arriving from Central and South America as well as older adults as the fastest-growing demographic, the student might consider selecting which elective course?
A) A course on medical Spanish
B) A psychology course on young adults
C) A personal finance class
D) A class on the effect of illness on a young child
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Answer: A
Explanation: A) Minorities in the United States will likely be the majority by the year 2042. By becoming proficient at other languages, such as Spanish, the nurse will be better able to meet the needs of the clients who seek care within the community. The largest group of clients will be age 65 or older in the near future, so an extra class about an aging population would be more helpful than a class about children or young adults. The student might consider a class on the effects of finance and cost in the delivery of healthcare rather than personal finance.
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352
) The manager of a small clinic has cross-trained the nurses to perform electrocardiogram (ECG) testing, phlebotomy, and some respiratory therapy interventions. This clinic is providing client-focused care. Which of the following actions shows this delivery model in action?
A) Many disciplines collaborate to provide client care.
B) Client care is carefully managed to control costs.
C) If a client complains of breathing difficulty, nurses concentrate on respiratory therapy for that client.
D) Client progress is efficiently tracked
Answer: C
Explanation: A) In client-focused care, the needs of the client, physical or emotional, as expressed by the client drive care decisions. Interdisciplinary collaboration, careful cost management, or efficient tracking of client progress are not distinguishing features of this model.
353
A nurse is planning a community health fair at a local community center. Which goals regarding health promotion does the nurse plan to highlight at the event? Select all that apply.
A) The ability to change and modify goals as health needs change
B) The ability for clients to be able to assess and evaluate their health needs
C) The ability for the client to promote health in other individuals
D) The ability to promote cost-saving techniques to healthcare providers
E) The ability to prevent disease by imitating nursing techniques
Answer: A, B
Explanation: A) The nurse has an integral role in health promotion. The nurse's aim should be to teach clients how to remain healthy, thus preserving wellness. The overarching goal is to ensure that clients understand the importance of setting health goals for themselves and their children, and that clients are able to assess, implement, evaluate and, as their health needs change, modify them. This does not include teaching clients to promote health in others, saving costs to healthcare providers, or actively preventing disease by imitating nursing techniques.
354
The nurse knows that communication among healthcare team members is essential during mass casualty events (MCEs). Which is essential when communicating under these circumstances?
A) Providing concise, accurate, and timely information
B) Preparing for ethical challenges
C) Documenting to prevent legal issues
D) Coordinating care between management and clinicians
Answer: A
Explanation: A) Communication among the various emergency team members must be concise, accurate, and timely during an MCE. Nurses must use their knowledge to foster better communication. Nurses face ethical and legal issues associated with the provision of care in MCEs, and they are also challenged as they decide what care to provide to patients; however, these issues do not directly affect communication even though they are affected by communication.
355
Why should job seekers in the healthcare sector pay attention to advances in healthcare technology?
A) Advances in technology require specialized personnel.
B) Advances in technology involve policies and strategies at the organizational level.
C) Changing demographics increase the need for new jobs.
D) Technology plays a role in health literacy.
Answer: A
Explanation: A) Many advances in technology require specialized personnel, creating new opportunities for individuals seeking employment in the healthcare sector. These advances may involve politics and strategies at the organizational level, but that is not of primary interest to job seekers. Changing demographics do not necessarily involve technology. Technology does play a role in health literacy, but this is not of primary interest to job seekers
356
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The nurse is taking care of a client who is being discharged but will need home nursing care, physical therapy, and speech therapy. Which framework helps the client who has multiple care needs?
A) Case management
B) Client-focused care
C) Managed care
D) A health maintenance organization
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Answer: A
Explanation: A) Multidisciplinary teams led by a case manager are at the heart of successful case management. Case management is essential when a client has multiple care needs and requires the services of multiple providers. The goal of case management is to reach and then maintain the individual's optimum level of health, quality of life, and activities of daily living by ensuring that the individual's healthcare needs are met. Client-focused care is focused on the client's expressed needs but not specifically on providing the services of multiple providers, managed care provides high-quality care at a lower cost but is not specifically focused on providing the services of multiple providers, and HMOs are a kind of managed care.
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) If more older adults live in Mississippi than elsewhere in the United States and clients in Massachusetts have much greater access to health services than clients elsewhere in the United States, then what does this imply about access of older adults to healthcare in Mississippi?
A) The likelihood is that more specialists serving older populations will work in Mississippi than in Massachusetts.
B) Their access to healthcare should be roughly equal to that of older adults living in Massachusetts but with a different mix of providers.
C) The need for services will be much greater for older adults in Mississippi than in Massachusetts due to a decreasing number of healthcare providers.
D) There will be much more robust rural services for older adults in Mississippi than in Massachusetts.
Answer: C
Explanation: A) No states have enough primary care providers to meet their needs. Aggravating this problem is the growing number of healthcare providers who specialize. If Massachusetts is a state with a much greater than average access for clients to health services, it is likely that states such as Mississippi offer less access to these services and fewer primary care physicians, and Mississippi's greater population of older adults will lack access to the care they need. Nothing here implies that there will be fewer specialists working in Massachusetts, and the trend is for more specialists everywhere. Nothing here indicates anything about the mix of providers in either state, and rural services tend to be lacking
358
The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. Which of the following is the best example of this problem for the educator to share with the students?
A) "Delays of diagnoses lead to higher mortality and morbidity rates."
B) "Delays in health coverage for children put the health provider at risk for litigation."
C) "Immunizations are free for children at public health clinics."
D) "Older adults are less likely to be treated for falls."
Answer: A
Explanation: A) Those who are not insured, or are underinsured, often do not seek treatment in a timely manner due to finances. As a result, diagnosis is made in the later stages of the disease, resulting in decreased chance of survival and an increased cost of treatment. The exposure of healthcare providers to litigation is not an aspect of this issue. Children with healthcare coverage receive preventive care such as immunizations and are more likely to stay healthy and do well in school. Adults age 65 and older are eligible for Medicare and have access to healthcare for falls and other medical problems
359
The nurse in an urgent care center is assessing an adult client who is diagnosed with the flu. The nurse discusses the need for flu shots with the client, who states, "I cannot afford the shots. I do not have health insurance." Which suggestion by the nurse is most appropriate?
A) Seek preventive care at the local health department.
B) Find a primary care physician who will give free care.
C) Obtain the flu shot at a local pharmacy.
D) Get the shot every year in the emergency department.
Answer: A
Explanation: A) Public health organizations, such as local health departments, are available for those who are uninsured or underinsured. This provides the client with health promotion and preventive measures as well as treatment when the client is ill. Using the emergency department for preventive care is part of the increased cost of healthcare. The nurse should not give the client a vague message that he or she needs need to find a care provider who gives free care. Rather, the nurse would refer the client to a specific place that can meet the client's needs. Flu shots at pharmacies require payment by the client and are not the solution for those with a low income and no insurance.
360
A client asks the nurse, "How am I going to pay for a surgery? I'm broke, but I've been so sick." Which statement regarding the Affordable Care Act (ACA) may be applicable to this client's situation?
A) "The ACA extends coverage to people who do not qualify for public assistance and whose employers do not offer health insurance."
B) "Unfortunately, you will probably be denied coverage because of your existing condition."
C) "Most insurance premiums will be more and some less; you will have to shop around."
D) "Because the rate of inflation is slowing, the ACA will also help curb medical costs."
Answer: A
Explanation: A) The ACA was created to ensure that all U.S. citizens have access to affordable, quality care and to curb the growth of healthcare costs. Under the ACA, a client cannot be denied coverage because of an existing condition. Insurance premiums should remain the same. The ability of the ACA to curb medical costs is irrelevant to this client's needs.
361
A nurse on the pediatric unit contemplates the changes in healthcare insurance for 2014 when speaking with other colleagues. Which aspects of the Affordable Care Act (ACA) affect children favorably? Select all that apply.
A) Insurance companies cannot deny coverage based on preexisting conditions.
B) Insurance companies cannot drop children who have serious illnesses.
C) Benefits are paid through private benefactors.
D) All children are covered regardless of whether the parents are covered.
E) The government must make appropriate arrangements for children based on need.
Answer: A, B
Explanation: A) Children with healthcare coverage receive preventive care and are more likely to attend school regularly and have better focus. The ACA will affect children favorably because insurance companies will no longer be able to deny coverage to children based on preexisting conditions or drop insured individuals and/or their dependents who experience serious illness. Under the ACA, benefits are not paid through private benefactors. Coverage is intended for all U.S. citizens, not just children and not only based on an assessment of need.
362
The nurse knows that Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 to prevent which action by emergency services?
A) Refusing to treat uninsured clients
B) Servicing suburban clients only
C) Stopping the poor from using emergency services as primary care
D) Providing free examinations to the poor
Answer: A
Explanation: A) In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Prior to the enactment of this law, providers of emergency services often refused to treat clients who were uninsured and who could not afford to pay for services. EMTALA does not have to do with provisions for nonsuburban clients, ensuring the poor use emergency services as primary care, or preventing free examinations to the poor.
363
) The nurse taking care of a client in the clinic notes that the client comes in twice per week, but never seems to have anything majorly wrong. Which is a benefit of providing education about self-care to this client?
A) The client's perception of need will change, promoting appropriate and timely healthcare.
B) The client will continue to come to the clinic seeking help until someone helps the client.
C) The client will seek affordable insurance by which to gain appropriate healthcare.
D) The client will learn to seek healthcare services from legitimate sources.
Answer: A
Explanation: A) A client's perceived need for healthcare services can be a barrier to access. It may cause clients to seek care that is unnecessary or care that is necessary but provided at an inappropriate and often more expensive place of service than needed. The nurse can change clients' perception of need (thereby promoting appropriate and timely healthcare) by managing client care, teaching adults about self-care and the care of their children, and teaching clients when and how to access appropriate care. An educated client will not continue to come to the clinic when there is no need. The issue here is not the need for affordable insurance or the inability to recognize legitimate sources of care.
364
At a local seminar discussing healthcare resources, the nurse discusses the phenomenon that healthcare resources are declining while costs for healthcare are increasing. An older adult in attendance asks the speaker why it has become so difficult to obtain needed care and services. Which response by the nurse is the most appropriate?
A) "There is increased cost due to the increased incidence of malpractice lawsuits."
B) "There is a decrease in the number of adults needing care."
C) "There are not enough medications produced for those who need them."
D) "There are plenty of nurses but not enough doctors."
Answer: A
Explanation: A) Services are reduced because of increasing costs and needs. One reason for increased costs is the practice of defensive medicine because of the risks of malpractice litigation. There is an increasing shortage of nurses and physicians. Over the next decade, there will be an increasing number of older adults needing medical care. The cost of supplies and medication, not the amount available, is the reason for decreased services.
365
The nurse is assessing an older adult client in the free clinic. The nurse notes that the client's cholesterol level is higher than the target and has increased since the client's last visit. The nurse assesses the client for possible causes for this increase. After determining that the client has not changed dietary and exercise habits, which conclusion by the nurse is the most appropriate?
A) The client has increased egg consumption.
B) The client may not be taking medications as prescribed.
C) The client needs more aerobic activity.
D) The client may be experiencing high triglyceride levels
Answer: B
Explanation: A) Rationing is a method used by individuals, insurance companies, and the government to prevent increases in the cost of healthcare or to reduce the cost of healthcare. Individuals ration when they decide to provide self-care for an illness or injury rather than seeking care from a healthcare provider. In the case of this client, rationing of prescribed medications is likely the issue because dietary and exercise habits have not changed, which rules out increased egg consumption or the need for more aerobic activity. Concluding that the client may be experiencing high triglyceride levels does not identify a reason for the increased cholesterol level.
366
A young mother brings her children to the health department for routine immunizations. The mother is crying because she lost her job and fears that her asthmatic daughter may be denied appropriate healthcare because she is unable to pay for it. The nurse realizes that many clients are experiencing these fears. Which action by the nurse would have the greatest impact for all clients who experience this fear?
A) Reminding the client that everything will be fine
B) Becoming involved in the American Nurses Association (ANA)
C) Moving to an area that needs healthcare workers
D) Giving the client medications and supplies from the clinic at no charge
Answer: B
Explanation: A) Because nurses are in a position to be closely associated with the needs of clients, nurses need to be involved in professional organizations that participate in educating legislators at the local and national levels. An example of such an organization is the American Nurses Association (ANA). For nurses to move to areas needing healthcare workers would not help with the rising cost of healthcare. Telling a worried parent that everything will be fine is giving the client potentially false hope. Giving clients supplies and medications from the clinic increases costs and will not help solve the overall problem with healthcare today.
367
A client in the clinic asks the nurse about a medication seen on television. When the nurse suggests a generic, cheaper version of the medication, the client is resistant to this recommendation. This is an example of which of the following?
A) Healthcare treatment choices that drive up costs
B) Factually misleading advertisements by pharmaceutical manufacturers
C) Client-focused care
D) The need for stricter Food and Drug Administration (FDA) safeguards for consumers
Answer: A
Explanation: A) Inappropriate healthcare treatment choices by consumers have also contributed to increases in healthcare costs. Mass advertising by pharmaceutical manufacturers and specialty treatment centers directed at consumers have contributed to these inappropriate treatment choices. However, this does not mean the advertisements are necessarily factually misleading. A client being guided in healthcare decisions by an advertisement is not an example of client-focused care or necessarily an argument for stricter FDA safeguards.
368
The local clinic staff has noticed an increase in the flu this season and requested more vaccine from the Centers for Disease Control and Prevention (CDC). The nurse knows that the CDC will control the vaccine distribution by considering which factors? Select all that apply.
A) The amount of vaccine being requested by local health departments
B) The speed at which the vaccine becomes available
C) Who gets the available vaccine
D) Ensuring that only medical personnel can receive the vaccine
E) Ensuring that only babies and military personnel receive the vaccine
Answer: A, B, C
Explanation: A) During 2009, there was an outbreak of H1N1 influenza. Initially an inadequate supply of vaccine was available, but as H1N1 began to spread, the CDC realized that guidelines had to be developed and implemented to ensure that the most vulnerable individuals had first access to the vaccine. As more vaccine became available, the CDC controlled its distribution by considering factors such as the amount of vaccine being requested by local health departments, the speed at which the vaccine was becoming available, and the need to ensure availability for not only the community but also active-duty military personnel. The CDC will not act to ensure that only medical personnel, babies, or military personnel receive the vaccine.
369
The nurse educator is teaching a group of nursing students about the methods that are used by insurance companies to ration healthcare resources. Which method does the educator include in the teaching session regarding this topic?
A) Denying coverage for services not supported by research
B) Covering clients for preexisting conditions only
C) Providing health savings accounts for covered individuals
D) Covering organ donations
Answer: A
Explanation: A) Rationing is one means of allocating healthcare resources. Rationing is a method used by individuals, insurance companies, and the government to prevent increases in the cost of healthcare or to reduce the cost of healthcare. Methods used by insurance companies to ration healthcare resources include noncoverage (e.g., noncoverage of preexisting conditions for up to a year after enrollment) and denial of coverage for services (e.g., services deemed to be experimental or those that are not supported by scientific evidence that proves their efficacy). Covering clients for preexisting conditions only, providing health savings accounts, and organ donation are not methods of rationing used by insurance companies.
370
As a working professional concerned with proper resource allocation, the nurse knows that one reason to join the American Nurses Association (ANA) is for which opportunity?
A) To participate in national discussions about resources
B) To draw attention to the nurse's credentials
C) To determine how to fight for resources locally
D) To advocate for resources through different business sources
Answer: A
Explanation: A) Nurses must be aware of and participate in discussions that affect the allocation of healthcare resources in the workplace, in their communities, and at the federal level. Nurses are uniquely placed to advocate on behalf of clients when allocation of resources is being considered in their communities. They may advocate by talking with local legislators, writing to politicians, and engaging in discussions in their neighborhoods and social groups. As working professionals, nurses have the opportunity to participate in national discussions about resources through a number of professional organizations, such as the American Nurses Association. ANA membership as regards resource allocation is not a means of building the nurse's credentials, fighting for local resources, or enlisting business sources in the provision of resources
371
The nurse is participating on a local council as an advisor regarding community needs during an emergency. Which recommendation regarding community needs during an emergency that the nurse might include when advising the council would be involved in the emergency response phase?
A) A coordinated emergency preparedness plan
B) Assembling disaster kits
C) Programs to restore the community
D) The identification of potential hazards to the community
Answer: A
Explanation: A) A coordinated response to emergencies occurs during the emergency response phase. Although a comprehensive disaster plan is developed in the preparedness phase, it is enacted in the emergency response phase. During the mitigation phase of the emergency response, the community identifies the potential hazards and takes measures to prevent or minimize the emergency. Assembling disaster kits is part of the preparedness phase. Programs to restore the community are part of the recovery phase.
372
) A hospital in the community has been notified of a multi-car crash on the interstate that will result in the transfer of many injured clients to the hospital. As part of the emergency response, the charge nurses in the emergency department (ED) and intensive care unit (ICU) are responsible for which tasks? Select all that apply.
A) Assigning care for the clients as they are admitted to the unit
B) Exceeding their scope of practice when and if required
C) Assessing the priority of the current clients for the ED or ICU
D) Delegating staff nurses to gather needed supplies for the arriving clients
E) Providing any care that any patient needs
Answer: A, C, D
Explanation: A) Nurses must observe both the physical and mental status of victims and ensure appropriate triage and treatment. They should not use their time to provide care that will be of minimal or questionable benefit. During the crisis, nurses should be constantly aware of their defined scope of practice and must not exceed it even when circumstances would seem to dictate otherwise. The charge nurses in each unit are responsible for assessing the current clients and recommending to the physicians those clients who can be moved to make room for clients needing more immediate care. The charge nurse would delegate the gathering of supplies to the staff nurses. The charge nurse would also assign care for the clients who are admitted to the unit.
373
The charge nurse assesses clients during a mass casualty incident (MCI) and transfers some to other units but discharges others to home. In planning for the admission of critically ill clients from the emergency department, to which nurses will the charge nurse assign the new clients when admitted to the unit?
A) Nurses with risk-reduction knowledge
B) Nurses with advanced assessment skills
C) Nurses with impeccable ethics
D) Nurses with exceptional self-care methods
Answer: B
Explanation: A) During the admission of injured clients, the charge nurse would assign the new clients to those nurses with advanced assessment, technical, and communication skills. Advanced practice nurses who have received training in emergency and trauma care will have significantly greater responsibilities than nurses with less training. Nurses do need to have good ethics, sufficient risk-reduction knowledge, and appropriate self-care knowledge during emergency responses. However, during the admission of victims, the charge nurse would want the highly competent nurses caring for the new clients.
374
A group of nurses attend an in-service regarding emergency preparedness for the hospital. One of the nurses has three small children and lives in a two-story house in the suburbs. After the class, the nurse plans to initiate which action to enhance family safety?
A) Training her family in performing nursing interventions to take part in an emergency response
B) Obtaining a fire escape ladder for the second floor of the home
C) Developing a plan for her family to join her in the event of an emergency
D) Ensuring she and her family move to a safe area unlikely to be involved in a disaster
Answer: B
Explanation: A) During the preparedness phase, nurses must also develop an emergency plan for themselves and their immediate families. When this plan is complete, nurses can be confident that their families are prepared to weather an emergency in relative safety. With this assurance, nurses who choose to assist in a disaster or who are required to remain at the hospital during a disaster will be able to leave their families without delay and remain available until no longer needed. Part of this plan should include means of escape such as fire escape ladders. The nurse's family is not qualified to perform nursing interventions and should go to a safe place in an emergency, not join the nurse where she is. No place is completely safe from all potential disasters.
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A nurse recently attended a seminar that discussed the many threats to homeland security. As nurse manager of the emergency department, the nurse is responsible for planning for emergencies from bioterrorism. Which agents does the nurse include when planning for bioterrorism? Select all that apply.
A) Anthrax
B) Tuberculosis
C) Cancer
D) Flu
E) Smallpox
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Answer: A, E
Explanation: A) Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern in regard to bioterrorism. Cancer, flu, and tuberculosis have not been developed into biological threats and would not kill the number of people that smallpox would
376
A nurse is performing START triage for clients injured in a terrorist attack. Which client would the nurse classify as expectant?
A) Client is breathing but has an absent radial pulse.
B) Client has a respiratory rate below 30.
C) Client is apneic after positioning of an airway.
D) Client is breathing adequately with a radial pulse but does not obey commands.
Answer: C
Explanation: A) A client who is apneic after the positioning of an airway would be tagged as black, expectant, meaning the client is not expected to survive. The other clients would all be classified as requiring immediate intervention.
377
The nurse is working with an emergency response team following massive flooding caused by a hurricane. What will working with the Clinical Outreach Communication Activity (COCA) team enable the nurse to do?
A) Have two-way communication with the Centers for Disease Control and Prevention (CDC) concerning infection risks.
B) Facilitate communication between doctors in the field during a disaster and their healthcare team.
C) Provide resources to the community during times of disaster.
D) Provide expert advice to other nurses during natural disasters
Answer: A
Explanation: A) The CDC manages the COCA to ensure that clinicians have up-to-date information. The COCA is designed to provide two-way communication between clinicians and the CDC about emerging health threats such as pandemics, natural disasters, and terrorism. The COCA keeps a list of emergency preparedness and training resources offered by federal agencies and COCA partners. COCA does not enable communication between doctors and their teams in the field, provide resources to communities during disasters, or enable communication between nurses during disasters.
378
) The nurse manager is discussing the preparedness phase of a revised emergency management plan for the emergency department. The American Nurses Association (ANA) is a resource the nurse manager can use to help nurses understand which of the following during an emergency response?
A) The ethics of emergency response
B) The procedure for working in a hot zone during a hazardous material incident
C) The role of the incident commander in a disaster response
D) The best means of communicating with agencies such as the Centers for Disease Control and Prevention (CDC) during a crisis
Answer: A
Explanation: A) During the preparedness phase, individual nurses must gain an understanding of their expected roles in an emergency and prepare for them. Because nurses will be required to allocate scarce resources and supplies and make unbelievably difficult client care decisions, they must understand the ethics associated with such choices. The ANA is a good source of information to guide nurses' understanding of their roles and possible consequences. Nurses must be aware of their employer's response plans and have a sense of how their state and local community will operate during an emergency. The ANA is not a primary source of information for working in hot zones, the role of the incident commander, or the best means of communicating with agencies such as the CDC
379
A nurse is responding in the aftermath of a hurricane. Hundreds of clients demand attention. The nurse will implement which of the following in assessing the priority of these clients?
A) Reverse triage
B) Standard emergency department triage
C) A disaster response plan
D) American Nurses Association (ANA) ethics rules
Answer: A
Explanation: A) Nurses perform triage every day in emergency departments. During a mass casualty event (more than 100 victims), the demand on nurses' knowledge and skills will be even greater. Mass casualty events call for the implementation of reverse triage, in which the most severely injured or ill victims who require the greatest resources are treated last to allow the greatest number of victims to receive medical attention. A disaster response plan involves the general response to an emergency. The American Nurses Association (ANA) guides nurses in making ethical decisions but does not specifically address the means of prioritizing client needs in a disaster.
380
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A railway accident causes the release of a dangerous chemical compound into the atmosphere. The nurse providing rapid triage and emergency treatment for clients in an effort to stabilize them knows that which is the primary purpose of the warm zone in this incident?
A) Decontamination
B) Rapid triage
C) Reverse triage
D) Emergency medical treatment
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Answer: A
Explanation: A) The warm zone (also referred to as the yellow, contamination, or contamination reduction zone) is located at least 300 feet from the outer edge of the hot zone. Although the primary purpose is decontamination, rapid triage and emergency treatment to stabilize victims may also take place in the warm zone. Individuals who have the highest levels of contamination are treated with the highest priority. Personal protective equipment (PPE) is required in this zone.
381
Terrorists have detonated a bomb in the downtown area of a major city, destroying part of a hotel, damaging nearby buildings, and killing or injuring an unknown number of people. A nurse in an emergency department handling many clients injured in the explosion receives a phone call from the babysitter for her children aged 5, 6, and 9, who says she's been watching the event unfold on TV since it happened. The nurse's family lives in a suburb more than 20 miles from the downtown. What should the nurse say?
A) "Explain to the children that the people who did this are sick and will be punished for what they've done."
B) "Please continue to watch the TV coverage with my kids in the room to ensure that you know what's going on at all times."
C) "Please tell my children I'm alright but turn off the television and play a game with them to get them thinking about something else."
D) "If you plan to continue to watch the TV coverage, please do it on the TV in my bedroom away from the kids."
Answer: C
Explanation: A) Limit the amount of media and news coverage children are exposed to, as this can be frightening to younger children. In this case, it would be best for the babysitter to engage the children in play that does not involve obsessively watching the news. Continuing to watch the news nonstop, trying to explain the tragedy in terms of crime and punishment, or watching the TV away from the children is not appropriate.
382
The detonation of several incendiary devices in a suburban area has caused widespread fires. A nursing home nearest one of the largest fires needs to be evacuated. What is the concern a nurse working in the home will have for his clients in this situation?
A) Socioeconomic limitations
B) Diminished sensory awareness
C) Inadequate thermoregulation mechanisms
D) Limited mobility
Answer: D
Explanation: A) Although diminished sensory awareness, inadequate thermoregulation mechanisms, and socioeconomic limitations all must be considered for older adults in an emergency, the primary issue that should concern the nurse in this situation is his clients' limited mobility. They need to evacuate, and doing so quickly could be difficult for many of his clients.
383
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The family members of a recently deceased client wrote a letter to the unit manager, expressing their appreciation for the way the client was treated while dying in the hospital. The family mentioned characteristics that indicate the nurses were caring. What behaviors did the family most likely use to explain the caring actions of the nurses? Select all that apply.
A) Delivered care with style
B) Treated the client as a human being
C) Respected the client
D) Maintained client confidentiality
E) Established limits with the client
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Answer: A, B, C, D
Explanation: A) Caring has been described as encompassing various intentions and actions. There are 10 behaviors within caring, which include appreciating the client as a human being, showing respect for the client, and treating client information confidentially. Delivering care with style describes aesthetic knowing, which includes the concepts of empathy, holistic thinking, compassion, and sensitivity. Establishing or setting limits is an action that a nurse would perform as part of self-care actions.
384
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During a care conference, the nursing student differentiates between the different theories of caring when discussing client care. Which type of knowledge is the student demonstrating?
A) Aesthetic knowing
B) Ethical knowing
C) Personal knowing
D) Empirical knowing
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Answer: D
Explanation: A) Empirical knowledge is systematic and helps to describe, explain, and predict phenomena. This student is exhibiting empirical knowing as the student is able to analyze the different theories of caring. Aesthetic knowing is the art of nursing and is expressed in creativity and style in meeting the needs of the client. Personal knowing is concerned with knowing, encountering, and actualizing the concrete, individual self. Ethical knowing focuses on matters of obligation or what ought to be done, and goes beyond simply following the ethical codes of the discipline.
385
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While caring for a client with respiratory alkalosis caused by hyperventilation, the nurse decides that having students in the room may increase the client's anxiety. Therefore, he decides to have the students watch the assessment of a different client. Which type of knowledge is the nurse demonstrating when assigning another client for care?
A) Empirical
B) Aesthetic
C) Ethical
D) Personal
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Answer: B
Explanation: A) Aesthetic knowledge is the art of nursing and is expressed by nurses in their creativity and style in meeting the needs of clients. This nurse is demonstrating aesthetic knowledge by being sensitive to the client's needs during the assigned shift. Empirical knowledge ranges from factual, observable phenomena to theoretical analysis. Personal knowledge is concerned with the knowing, encountering, and actualizing of the concrete, individual self. Ethical knowing focuses on matters of obligation or what ought to be done, and goes beyond simply following the ethical codes of the discipline.
386
During a performance appraisal, a unit manager praises a staff nurse on the ability to use presencing when caring for terminally ill clients. What did the nurse demonstrate that would exemplify this caring behavior? Select all that apply.
A) Face-to-face discussions with clients
B) Instructing clients on how they should perform certain functions
C) Sitting quietly with clients
D) Validating the client's experience through active listening
E) Guaranteeing quality and safety in care
Answer: A, C
Explanation: A) Presencing is a nursing concept that involves the interpersonal arts of perception and communication. Presencing is described as face-to-face discussions, silent immersions, and lingering presence. Instructing clients on how they should perform certain functions empowers the client. Guaranteeing quality and safety in care demonstrates competence. Validating the client's experience through active listening demonstrates compassion.
387
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The nurse decides to take a few days of personal time to invest in self-nurturing activities. Which activities indicate the nurse is taking steps to care for self? Select all that apply.
A) Sleeping 4 hours each night
B) Eating one meal a day
C) Being active in church
D) Participating in regular exercise
E) Participating in daily meditation
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Answer: C, D, E
Explanation: A) Some examples of activities that can help the nurse care for self include a balanced diet, regular exercise, adequate rest and sleep, recreational activities, and meditation and prayer. Eating only once a day and sleeping for 4 hours each night are not activities that help the nurse care for self.
388
A hospital is preparing for the American Nurses' Credentialing Center's magnet hospital designation process. Nurse representatives on the Magnet Council consider several Professional Practice Models (PPMs) as their approach to nursing care. After selecting a PPM model, members of the Council plan a series of nursing grand rounds. These focus on the six Cs of caring in nursing: compassion, competence, confidence, conscience, commitment, and comportment. What particular nursing theory, philosophical approach, or framework of caring have the nurses decided to adopt?
A) Watson's Theory of Human Care
B) Leininger's Theory of Culture Care Diversity and Universality
C) Roach's Theory of Caring as the Human Mode of Being
D) Boykin and Schoenhofer's Nursing as Caring Theory
Answer: C
Explanation: A) Roach's Theory of Caring as the Human Mode of Being includes the six Cs of caring in nursing. The other three approaches to caring in nursing focus on other major tenets related to caring. Watson's Theory of Human Care emphasizes the role of authentic caring relationships in healing. Leininger's Theory of Culture Care Diversity emphasizes actions that preserve, maintain, and accommodate the cultures of diverse clients, and Boykin and Schoenhofer's Nursing as Caring Theory describes caring as an essential aspect of nursing and a process rather than a mere goal.
389
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A nurse in a rural community is employed in a facility that has had a shortage of nurses for several years. As a result, several nurses have left the institution citing burnout. To avoid risking burnout, the nurse regularly works out, practices yoga, socializes with friends once or twice a week, and participates in at least one annual national or state nursing conference. This approach to work-life balance reflects which concept within the framework of Caring Interventions?
A) Self-compassion
B) Self-care
C) Self-control
D) Self-actualizing
```
Answer: B
Explanation: A) Given the circumstances in which the nurse finds himself, the nurse has initiated the Caring Intervention of self-care to help him better cope with a stressful work environment. Although self-care involves aspects of having compassion for the self, exercising self-control, and being self-actualizing, self-care is the term included as part of the Caring Interventions framework that enhances nurses' professional practice and helps them to avoid burnout.
390
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When a client's or family's wishes about a client's care clash with what the nurse believes would be the best possible care for the client, this could cause a conflict between caring interventions and what other nursing concept?
A) Accountability
B) Ethics
C) Quality Improvement
D) Communication
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Answer: B
Explanation: A) Conflict between providing the best possible care for the client and the family's or client's wishes could lead to the nurse experiencing moral distress, which could lead to burnout. This is an ethical conflict for the nurse. Even in the midst of this conflict, the nurse should maintain the highest standards of accountability and communication. The nurse may use this situation to analyze institutional policies for quality improvement, but this process would not involve conflict.
391
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9) In holistic nursing, the nurse should emphasize the client's personal responsibility in maintaining health. This idea is most closely related to which concept in caring interventions?
A) Nursing presence
B) Empowerment
C) Compassion
D) Competence
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Answer: B
Explanation: A) Empowerment is the process whereby the client develops the autonomy to identify her own health needs in lieu of being instructed how to do so. This helps the client take personal responsibility in maintaining health. Nursing presence, compassion, and competence are less likely to help clients take personal responsibility for their own health.
392
The pediatric nurse is caring for a 17-year-old client who has type 1 diabetes. What caring intervention can the nurse implement as the client transitions to adulthood?
A) Advocate for the client to receive pain-relieving interventions for routine procedures such as blood glucose tests.
B) Encourage the client to use a retail clinic for acute care problems unrelated to diabetes.
C) Emphasize the importance of having a medical home to routinely monitor and treat chronic conditions.
D) Provide recommendations for a provider who can integrate all findings from specialists into a comprehensive overview.
Answer: C
Explanation: A) A large care gap exists as young adults transition from pediatric care, monitored by parents, into autonomous primary care. Many young adults neglect to get care for chronic childhood conditions such as asthma or diabetes, so nurses should emphasize the importance of having a medical home and routinely monitoring and treating chronic conditions. Because of the need for consistent care and follow-up, a retail clinic would not be beneficial for this client. The use of pain-relieving interventions for routine procedures is more appropriate for infants, not adolescents or young adults. Finding a provider who can integrate all findings from specialists is more important for older adults than for young adults.
393
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The nurse is caring for an older adult client who visits the clinic semiannually to help maintain quality of life. When providing caring interactions to this client, what intervention should the nurse avoid?
A) Self-care
B) Assessment for mental health problems
C) Referral to a geriatrician
D) Use of elderspeak
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Answer: D
Explanation: A) Elderspeak is a simplified speech characterized by shorter sentences and words. This type of speech shows a negative attitude toward older adults, especially adults who are generally healthy and are only seeking care to enhance quality of life. Assessments of older adults should include mental health problems, and older adults may be referred to a geriatrician as needed. Self-care is related to the nurse caring for one's self, not the nurse caring for a client.
394
A female client, from a male-dominated culture, is being discharged after a lengthy hospitalization. Which action by the nurse prior to providing discharge instructions is appropriate?
A) Assess who the decision maker is in the family.
B) Ensure that the healthcare provider gives the instructions.
C) Make sure instructions are understood by the client.
D) Ask the client when the best time for teaching would be.
Answer: A
Explanation: A) The nurse needs to identify who has the "authority" to make decisions in a client's family. If the decision maker is someone other than the client, the nurse needs to include that individual in healthcare discussions. Nurses need an awareness of cultural variations of gender because they will be caring for diverse client needs. What might be considered sexism by one culture may not be in another. Regardless of who is present during the teaching, it is always necessary to make sure that the instructions are understood, but it is difficult to do that before instructions are given. Asking the client when the best time for teaching would be does not address the need for the decision maker of the family to be present. The nurse should not simply leave giving instructions to the healthcare provider
395
A novice nurse is working in a busy emergency department of a hospital situated in a culturally diverse area of the city. Which should the nurse do when providing culturally competent care?
A) Acquire the underlying background knowledge necessary that will provide these clients with the best possible healthcare.
B) Treat everyone who comes to the emergency department seeking care as having the same needs.
C) Assume that working in this emergency department will be the same as in other care contexts the nurse has encountered.
D) Base the standard of care on the needs and attitudes of the dominant cultural group in the area.
Answer: A
Explanation: A) As healthcare providers, it is imperative to recognize common prejudices. Prejudices are prejudgments about cultural groups or vulnerable populations that are unfavorable or false because they have been formed without the background knowledge and context upon which to form an accurate opinion. Healthcare providers must acquire this background knowledge to develop their cultural competence. The nurse cannot treat every client as having the same needs, assume that the emergency department does not present a unique context that must be understood on its own terms, or base his standard of care on what best serves a single cultural group, dominant or not
396
A nurse is explaining the need to obtain laboratory tests on a client who has an infection and is of a cultural group different from the nurse's. During the interview, the client avoids eye contact and refrains from answering questions for long periods of time. Which does this behavior indicate to the nurse?
A) In this client's culture, direct eye contact may show disrespect.
B) The nurse should come back at a different time when the client is feeling more communicative.
C) The nurse should have another nurse finish the interview who might be more culturally aware of this group's customs.
D) Leave the room and come back after having learned more about this particular culture.
Answer: A
Explanation: A) Nonverbal communication includes silence, touch, eye movement, facial expressions, and body posture. In some cultures, direct eye contact may indicate disrespect. In addition, some cultures are quite comfortable with long periods of silence. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility that the behavior may have a different meaning for the client and family. The nurse should not leave to come back later or try to find another nurse to take over this client's care; nurses should be able to communicate with clients from a diversity of backgrounds
397
The nurse is caring for a client from a different culture who had a myocardial infarction and is receiving atorvastatin (Lipitor). The nurse assesses the client's diet to be very high in fat. Which is the best plan by the nurse to improve the client's diet and reduce the risk that the client may need additional medications?
A) Ask the client if he would rather have another nurse who is from the same culture speak to him about his dietary needs.
B) With the client's permission, discuss the dietary requirements with whoever prepares meals for the family.
C) Consult a dietitian to teach the client about low-fat diets.
D) Give the client information specific to his culture related to low-fat diets.
Answer: B
Explanation: A) Every culture has culture-specific diets; the nurse must include the individual in the family who does the meal preparation if a different diet is to be successful. Asking the client about having a nurse from the same culture speak to him is racist and implies that the nurse cannot understand the dietary needs of a client from another culture. At this point, a consult by dietary services is premature. Providing information is a good idea, but the nurse must also teach the client
398
The nurse is evaluating the following goal: Client will select low-fat foods from a list by the end of the month. The client, who has different beliefs about food, has not been able to achieve this goal. Which action by the nurse is appropriate?
A) Extend the time frame and give the client a longer period to achieve the goal.
B) Select a different goal.
C) Make sure that the client understands the importance of the goal.
D) Modify the plan of care to be consistent with the client's beliefs regarding food.
Answer: D
Explanation: A) If the outcomes are not achieved for a client with different beliefs, the nurse should be especially careful to consider whether the client's belief system has been adequately included as an influencing factor and modify the plan of care to be consistent with the client's belief regarding food. Extending the time frame, selecting a different goal, or checking how the client understands the importance of the goal may not be as helpful as looking at the cultural practices–including dietary ones–of the client.
399
The nurse places a client in a treatment room of the emergency department for treatment of abdominal pain and vaginal bleeding. The spouse, speaking for the client, asks that only a female provider examine his wife for the pelvic exam. The nurse recognizes that the client is from a culture that prohibits men from examining women. Which is the most culturally appropriate statement by the nurse?
A) "Your spouse will be covered with a sheet, so it will not matter whether the examiner is male or female."
B) "The male and female providers both respect privacy."
C) "The request is unreasonable and cannot be honored."
D) "Every attempt will be made to honor your request."
Answer: D
Explanation: A) Many cultures have religious beliefs that prohibit men from examining women and women from examining men. To provide culturally appropriate care, the nurse must recognize this as a legitimate request and make every attempt to honor this request. Although both male and female staff have professional and ethical responsibilities to respect a client's privacy, the nurse must still make efforts to meet the request of the client. The response of covering the client or stating the request is unreasonable shows insensitivity to the client's cultural need
400
The client is admitted to the hospital following a miscarriage, and she is septic. The healthcare provider orders antibiotics, which the client refuses, stating, "I don't deserve them. I lost my baby because I had sex outside of marriage." Which is the appropriate response by the nurse?
A) "I'll notify your healthcare provider about your decision."
B) "Do you think you should be punished because you had a miscarriage?"
C) "I think you need to do what is best for you."
D) "You have a serious infection and really need the medication."
Answer: D
Explanation: A) Telling the client she needs the medication is providing the best care possible. Telling the client she needs to do what is best is inappropriate; the nurse knows she needs the medication. Calling the healthcare provider is inappropriate; the nurse knows the client needs the medication. Asking the client if she thinks she should be punished is inappropriate; she is septic and needs the medication.
401
The nurse is caring for a client who just had abdominal surgery. The client's nonverbal cues indicate pain, but the client denies the need for the pain medication prescribed by the healthcare provider. The nurse recognizes that this client is from a culture that feels it is inappropriate to complain about pain. Which action by the nurse is appropriate?
A) Seek out a family member to convince the client to take the medication.
B) Consult with the healthcare provider about providing pain medication without the client's knowledge.
C) Offer the pain medication to the client again, stating that providing comfort is the nurse's most important responsibility.
D) Allow the client to suffer in silence.
Answer: C
Explanation: A) Members of some cultures will typically not complain of pain or physical problems because they are taught self-restraint and the priority of the group over individual needs. Many people from these cultures will consider refusal of something offered as a gesture of courtesy. The nurse should take this into account when offering the pain medication to the client in a culturally sensitive way. Seeking out the intervention of a family member of the client, trying to administer the medication without the client's knowledge or simply allowing the client to suffer in silence are not appropriate actions.
402
The clinic nurse is caring for an infant during a routine wellness exam. The parents and infant immigrated to the United States 6 months ago. The mother explains that she believes that an herbal remedy is the best way to treat the infant's colic. Which action by the nurse is appropriate?
A) Ask the mother what the ingredients are in the remedy.
B) Give the mother an alternate remedy for colic.
C) Explain how herbal ingredients may be harmful to the infant.
D) Tell the mother not to use the remedy because there is no way to know what the ingredients' scientific effect may be.
Answer: A
Explanation: A) To recognize cultural practices, the nurse must acknowledge that use of old and home remedies is part of caregiving practices. Asking the mother what ingredients are in the herbal remedy allows the nurse to best evaluate what the mother is using, and then a determination of the benefit or detriment to the infant can be made in a nonjudgmental manner. Telling the mother not to use the remedy, giving an alternative, or making a judgment that any herbal ingredient is harmful does not recognize this cultural practice and shows insensitivity on the part of the nurse.
403
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During a sexual history, the client states, "I have always felt like a man trapped in a woman's body." The nurse should recognize that the client may identify as what?
A) Bisexual
B) Heterosexual
C) Homosexual
D) Transgender
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Answer: D
Explanation: A) The term transgender refers to individuals who do not identify with the gender assigned to their body. For example, an individual who identifies as transgender may have typical female anatomy but feel like a male and seek to become male by presenting as male and taking hormones or electing to have sex reassignment surgeries. This client's statement relates to gender identification, not to the sexuality of the client.
404
A nurse is working at a healthcare clinic serving the needs of an inner-city population that is predominantly made up of minority people groups. A neighbor says the nurse must be brave because most of "those" people have guns and are in gangs. Which response by the nurse is appropriate?
A) "It's very difficult for me when you discriminate like that."
B) "It's okay because I'm not a gang member, so I will be okay."
C) "Hey, it's a job like any other job. All jobs have problems."
D) "That's an unfortunate stereotype. Can we talk about the reality?"
Answer: D
Explanation: A) It is the nurse's role to promote the act of bridging, linking, or mediating between groups of people from different cultural systems to reduce conflict or produce change. Calling the neighbor's comment discriminatory may increase conflict. Rationalizing or failing to confront the neighbor's perceptions does not promote cultural brokering.
405
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A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the lack of resources this client has available, which should the nurse assess during the intake phase of the health history? Select all that apply.
A) Social support available
B) Access to medication
C) Access to nutritious meals
D) Number of times married
E) Any personal resources
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Answer: A, B, C, E
Explanation: A) Homeless clients present unique and complex challenges. The nurse should inquire about any social support, personal resources, and access to prescribed medications and nutritious meals in order to plan care appropriately. The number of times the client has been married is irrelevant
406
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A nurse is working with a number of clients at a free clinic. Which client population is at the highest risk for low levels of healthcare?
A) Undocumented immigrants
B) Men who have protected sex with men
C) Men who have sex with women
D) Teenagers
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Answer: A
Explanation: A) The term "vulnerable population" refers to groups of people in our culture who are at greater risk for diseases and reduced life span due to lack of resources and exposure to more risk factors. People may be made vulnerable by immigration status. Men or teenagers as a group are not more likely to be at risk for lower levels of healthcare.
407
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Which treatment program would be most appropriate for homeless clients whose type 1 diabetes requires daily insulin injections?
A) Home healthcare
B) Outpatient clinic
C) Partial hospitalization programs
D) Inpatient hospital-based care
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Answer: B
Explanation: A) The outpatient clinic would provide the care the client requires in the most cost-effective manner. There is no indication for inpatient or partial hospitalization at this time.
408
The novice nurse working in an inner-city hospital that serves a diverse client population states, "I want to learn everything possible about all of the clients." Which response by the seasoned nurse is appropriate?
A) "I will give you a great book that describes all of the critical factors."
B) "You should always be nonjudgmental."
C) "This will come with time as you get to know clients and then encounter problems."
D) "You need to first understand who you are."
Answer: D
Explanation: A) It is a priority for the nurse to develop an awareness of his or her own perceptions, prejudices, and stereotypes regarding the client populations that are served. Reading about culture and remaining nonjudgmental are strategies that can be incorporated after engaging in a self-awareness inventory. Although experience working with diverse clients will help, it will be more meaningful after engaging in a self-awareness inventory
409
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The nurse is reviewing the discharge instructions for administration of home medications with an older adult client. In considering the normal changes experienced with aging when developing a teaching plan for this client, what type of bias should the nurse be careful to avoid?
A) Relativism
B) Fundamentalism
C) Ageism
D) Multiculturalism
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Answer: C
Explanation: A) Ageism is discrimination against older adults, which the nurse should guard against when developing a teaching plan for this client to ensure that no part of it depends on biases about older adults. Relativism and fundamentalism are ethical philosophies. Multiculturalism is many cultures existing in a society in which no culture dominates.
410
A nurse working in an assisted living facility is preparing an educational program regarding ageism for the colleagues on the unit. Which statements reflect ageism? Select all that apply.
A) "If the client is competent to make decisions, I should not go to other members of the family for care decisions."
B) "The elderly are just lazy, and that is why they need help with activities of daily living."
C) "All elderly people are sickly."
D) "Addressing an elderly client as 'Honey' or 'Sweetie' is disrespectful."
E) "The elderly are less likely to recover from illness."
Answer: B, C, E
Explanation: A) Ageism is the term used to describe the deep and profound prejudice in American society against older adults. The beliefs that elderly people are sickly, less likely to recover from illness, and lazy are all examples of ageism. The nurse should always address the client by name and involve the client in care decisions if the client is competent to decide.
411
Which acculturation behavior will the nurse observe in a client who has emigrated from another country to the United States?
A) The client buys all needed products from the local store owned by people from the client's country.
B) The client lives in a neighborhood that is populated predominantly with people from the client's country.
C) The client speaks his native language only.
D) The client attends church in the neighboring community to meet new people.
Answer: D
Explanation: A) Individuals experience acculturation when they begin to adapt or borrow habits of the new culture. The client who attends church in the neighboring community to meet new people is displaying acculturation. The other behaviors are examples of a client who may feel comfortable only in the client's culture.
412
The nurse notices that a client, who is from another country, appears uncomfortable when the nurse asks to look at the client's abdominal incision from a recent surgery. Which nursing action is the most culturally competent?
A) Close the client's curtain to maintain privacy.
B) Ask the client to explain why she is uncomfortable.
C) Explain the reason for the intervention using lay terms.
D) Wait until the next assessment time to observe the incision.
Answer: C
Explanation: A) The most culturally competent intervention is to explain to the client the reason for the intervention using lay terms. The nurse should close the client's curtain to maintain privacy for all clients; this is not necessarily just a culturally competent action. Asking the client why she is uncomfortable is confronting the client and is not culturally competent. Waiting until the next assessment time to observe the incision is inappropriate, as this can lead to missing important assessment findings regarding the state of the client's incision.
413
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A general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male is
A) homosexual.
B) transgender.
C) genderqueer.
D) intersex.
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Answer: D
Explanation: A) Intersex is a general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male. Homosexuality is a sexual preference for members of the same sex. Transgendered individuals do not identify with the gender assigned to their bodies. Genderqueer individuals don't identify with male or female exclusively but with both categories.
414
The nurse caring for an adult client from another country notices that the client consults with her mother on all healthcare decisions. What action by the nurse is the most culturally competent?
A) Ask the client why the parent is being consulted for every decision.
B) Accept the behavior of the client and family member.
C) Ask the client's mother to leave the room to provide the client with more privacy.
D) Confront the client's mother to state the importance of the client making her own decisions.
Answer: B
Explanation: A) In a multicultural society, human differences are accepted and respected. The nurse should accept this behavior because it might be a cultural norm, or it may be the way this client prefers to approach decisions about healthcare. Either way, all other choices are inappropriate and do not consider the client's cultural, family, or personal values.
415
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A nurse, who works in a clinic environment, places great emphasis on cost control, customer satisfaction, health promotion, and preventive services. The primary focus of this nurse is representative of which type of healthcare system?
A) Functional method
B) Client-focused care
C) Case method
D) Managed care
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Answer: D
Explanation: A) Managed care describes a healthcare system whose goals are to provide cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. The case method of care is a client-centered model in which one nurse is assigned to care for a group of clients during an 8- to 12-hour shift. The functional method of care focuses on jobs to be completed and is task oriented. Client-focused care is a delivery model that brings all services and care providers to the client.
416
A nurse is completing discharge teaching for a client who is hospitalized for total hip replacement. The client asks the nurse why there is a case manager involved and expresses confusion about who is in charge. The client states, "I thought my doctor manages my care." Which is the best response by the nurse?
A) "No, I manage your care."
B) "You are correct; the doctor is responsible for managing your care."
C) "A case manager coordinates everyone involved in your care to ensure your needs are met."
D) "The case manager delegates your care to the nurse."
Answer: C
Explanation: A) The case manager is responsible for ensuring that all the client's healthcare needs are met in a cost-effective manner. The nurse may be a case manager; however, a staff nurse is not the most likely individual in the hospital setting to be the case manager. An agency usually has several case managers who collaborate with nursing, the physician, and any other departments involved in the care of the client. A physician does not participate in care by being a case manager. Case managers coordinate disciplines of care for the client and do not delegate any care to other professionals.
417
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A novice nurse is looking for employment and hopes to find a facility where the nursing staff participates in making, implementing, and evaluating client care policies. Which organizational module implements these practices?
A) Client-focused care
B) Differentiated practice
C) Managed care
D) Shared governance
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Answer: D
Explanation: A) Shared governance is an organizational model in which nursing staff are cooperative with administrative personnel in making, implementing, and evaluating client care policies. Differentiated practice is a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets. This model consists of specific job descriptions for nurses according to their education or training. Client-focused care is a delivery model that brings all services and care providers to the client. Managed care focuses on cost containment, consumer satisfaction, health promotion, and preventive services.
418
The nurse is appointed to a clinical-administrative task force studying critical staffing issues and care delivery models for the hospital. Which evidence on the effects of different staffing choices and care delivery models should the task force consider? Select all that apply.
A) Higher nurse-to-client ratios have been linked to a decrease in the amount of time clients are hospitalized.
B) Shared governance is linked to a reduction in adverse outcomes.
C) A higher proportion of registered nurses can reduce the risk of mortality in surgical clients.
D) Research indicates that functional assignment of staff improves the likelihood of meeting clients' emotional needs.
E) There is little or no research studying nursing ratios and client outcomes.
Answer: A, C
Explanation: A) Higher nurse-to-client ratios have been associated with shorter lengths of stay and fewer complications. A recent study depicted a significant reduction in the risk of mortality in surgical clients when the proportion of registered nurses was higher. There is little research on care delivery models since it is more difficult to compare outcomes because each unit may employ slight variations of the model. Research continues to prove that higher nurse-to-client ratios result in fewer adverse outcomes for clients.
419
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A nurse is applying for a job as a case manager for a managed care insurance organization. Which responsibility is associated with this role?
A) Providing home visits to clients
B) Independent treatment planning
C) Coordinating client care over time
D) Approving treatment decisions
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Answer: C
Explanation: A) Insurance-based case management is a labor-intensive activity that is provided typically by telephone, not home visits. Case management involves interdisciplinary teams that assume collaborative responsibility for planning and assessing needs, not independent planning. Case management involves coordinating, implementing, and evaluating care for groups of clients from preadmission through discharge or transfer and recuperation. Approving treatment decisions is not a case management role.
420
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) What nursing concept is essential to ensure continuity of client care when a nurse is managing the care of a client?
A) Ethics
B) Communication
C) Advocacy
D) Teaching and Learning
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Answer: B
Explanation: A) Communication among members of the collaborative team of healthcare providers is essential to ensure continuity of client care. Although ethics, advocacy, and teaching and learning are important for managing care in general, they do not directly influence the continuity of care.
421
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The nurse is helping with discharge planning for a client who needs extensive rehabilitation and is on a complicated medication schedule. The client and spouse currently live with their eldest son, and the family is very involved in the client's care. The nurse would want to coordinate the client's daily care by including which priority individuals? Select all that apply.
A) Pharmacist
B) Client's children
C) Primary healthcare provider
D) Social worker
E) Client's spouse
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Answer: B, E
Explanation: A) Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and healthcare professionals the opportunity to plan care and set goals. Involving the client's spouse and children would be important in this situation because of the complexity of the client's situation. The physician, pharmacist, and social worker are important for the coordination of care in general, but they would not be involved in daily care in most circumstances.
422
) The nurse is caring for a preschool-age client who suffered brain damage following a car accident. The client has a tracheostomy, is ventilator-dependent, and will be discharged from the hospital into the family's care. The family wants to care for the child at home but does not have the resources for 24-hour care. Which action by the care manager is appropriate?
A) Making referrals to a variety of community-based agencies that can meet the family's needs
B) Telling the family that it is impossible to provide care at home
C) Arranging for the child to be sent to a long-term healthcare facility
D) Contacting local nurses in the community to provide the assistance that the family needs
Answer: A
Explanation: A) The referral process is a systematic problem-solving approach that helps clients use resources that meet their healthcare needs. The nurse should not tell the family they cannot care for the client at home, nor should the nurse arrange for the child to be sent to a long-term care facility, because these actions do not reflect the family's wishes. Contacting local nurses would not be an efficient way to manage this client's care
423
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A nurse is caring for a client who had a total hip replacement 14 days ago. The client is preparing for discharge in a few days. The nurse facilitates a care conference with the primary healthcare provider, occupational therapist, physical therapist, and the client and family to develop a plan of care for the client prior to discharge. Which roles are being demonstrated by this nurse? Select all that apply.
A) Coordinator
B) Collaborator
C) Differentiated practitioner
D) Team leader
E) Expert
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Answer: A, B
Explanation: A) The nurse is solving problems and planning care for the client by coordinating and collaborating with the other health team members who will participate in client care. All members of the team may be experts, but the level of expertise is not the role the nurse is exhibiting. The nurse is not responsible for how the members of the health team perform their jobs as a team leader would be. Differentiated practice involves nursing care from all levels of education and is not illustrated in this scenario
424
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A nurse working in an outpatient OB-GYN clinic is asked to assume the case management for the clinic's adolescent clients. Which skills will the nurse need to perform this work?
A) Critical thinking
B) Physical assessment
C) Relaxation training
D) Accounting
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Answer: A
Explanation: A) Critical thinking skills are crucial to the development of a well-coordinated care plan and its execution. Relaxation training skills and accounting skills are not a part of care coordination. Although the nurse may need to assess the plan of care and make adjustments as needed, the nurse in the role of case manager may not be required to perform physical assessments on the client.
425
The nurse is reviewing client records to determine which clients are good candidates for case management. Which client would the nurse choose as having the highest priority for assigning a case manager?
A) A newborn who was diagnosed with cerebral palsy
B) A pregnant woman with three other children
C) A school-age child who was diagnosed with pneumonia
D) An older adult who has been diagnosed with hypertension
Answer: A
Explanation: A) Some clients are more likely to benefit from case management than others, including at-risk pregnant women, children with congenital conditions, and older adults with many chronic conditions. A newborn diagnosed with cerebral palsy has a congenital condition that will require lifelong care. The pregnant woman does not appear to be at risk from this description. The school-age child has an acute condition, not a chronic condition. The older adult has a chronic condition, but in the absence of other complicating factors, this one condition would not require case management.
426
The nurse is managing the care of an older adult client who is near the end of life but still has treatment options available. The treatment options could potentially be painful and expensive, and they would only extend the client's life approximately 2 months. What important topic should the nurse include during initial discussions with the client and family?
A) The need for hospice care for the client
B) Referral for grief counseling for the family
C) Reasons why the client should remain in the hospital until death
D) The client's health and impending mortality
Answer: D
Explanation: A) When providing case management for a client near the end of life, the case manager's first step in ensuring the client's wishes are met is to speak honestly to the client about his or her health and impending mortality. Hospice care should be presented as an option, but only if the client chooses not to receive additional treatment. The client should be given the choice of where he or she wants to die, not be encouraged to remain in the hospital until death. Grief counseling for the family would come at a later appointment, not during initial discussions.
427
An older adult client tells the nurse, "I am worried about how I will pay for my hospital bill." The client is being discharged, is being referred to home healthcare, and the new plan of care involves extremely expensive drugs. Which response by the nurse is appropriate?
A) "You need to focus on recovering and not worry about finances."
B) "I'll have someone from the business office come and set up your payment plan."
C) "Don't worry. I'm sure everything will work out okay."
D) "Much of your care will be covered by Medicare."
Answer: D
Explanation: A) Medicare provides a health insurance program for adults over the age of 65. A large portion of this client's bill will be covered by Medicare. Ignoring the client's concerns by telling him not to worry is not therapeutic communication and does little, if anything, to confront the client's concerns. Passing the concern to the business office does not address the client's concerns.
428
The nurse is caring for an adult client from Canada who has come to the United States for a serious neurologic surgery. The client tells the nurse, "I came to this country so that I would receive the care I need." Which is the most likely rationale for the client's statement?
A) The U.S. has many choices about healthcare.
B) The U.S. has a universal healthcare system.
C) Healthcare rationing in the U.S. decreases cost.
D) There is very little competition in healthcare in the U.S.
Answer: A
Explanation: A) Americans with health insurance have more of a choice about their healthcare than do other nations of the world. Canada, not the United States, has a universal healthcare system. Most other countries do not allow for competition in healthcare, but the United States does. Rationing is one reason why clients come to the United States; with rationing, an individual could wait months for needed surgery.
429
An instructor is teaching the class about cost-conscious nursing practice. The instructor knows that the students understand this concept when the students make which statements? Select all that apply.
A) "Nurses must search for more efficient ways to deliver nursing care."
B) "Careful use of supplies will reduce waste and save money."
C) "I do have to take shortcuts every now and then."
D) "There are insufficient healthcare workers to meet the need right now."
E) "A new emphasis has been placed on health promotion and disease prevention."
Answer: A, B, E
Explanation: A) Nurses at all levels face significant pressures to become more cost conscious. This level of financial accountability is new to the nursing profession. Nurses must now compete with other departments within organizations for limited resources. Nurses can be more cost-conscious by carefully using supplies, by searching for more efficient ways to deliver nursing care, and by placing a new emphasis on health promotion and disease prevention. Taking shortcuts can lead to mistakes, and client care should never be compromised. It is true that there are insufficient healthcare workers to meet needs, but this does not contribute to cost-conscious nursing care.
430
A client recovering from an emergency appendectomy is a citizen of a foreign country. The client asks the nurse to explain why the United States has chosen such a different healthcare reimbursement system from other Western countries. Which American value could the nurse mention to explain the system in this country?
A) Acceptance of the role of government
B) Individual freedom
C) Skepticism about markets and competition
D) Universality
Answer: B
Explanation: A) In the United States, individual freedom is valued over the role of the government in healthcare. The U.S. system is based on market competition. In the United States, pluralism and choice are often valued over universality
431
A nurse working in a large municipal hospital is appointed to a task force whose focus is addressing nursing shortages. Which factor should the task force consider?
A) Nurses are only used for clinical services.
B) Nursing shortages contribute to salary fluctuations.
C) Only licensed nurses are used for all nursing duties.
D) Reductions in nursing staff encourage nurses to remain in the profession.
Answer: B
Explanation: A) When nursing shortages occur, employers must increase wages in order to hire and retain staff. As the positions are filled, employers slow the rate at which they increase wages, causing salary fluctuations. Nurses have been replaced by unlicensed assistive personnel (UAP) as a cost-containment measure, and many nursing duties are now performed by UAPs. Nurses are also now being hired in new roles that do not include clinical services, such as case management for managed care organizations. As a result of reductions in nursing staff, some nurses, feeling they can no longer provide quality healthcare, experience disillusionment and leave the profession.
432
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What action will allow facilities to better track the cost effectiveness of various nursing actions and allocate nursing resources most efficiently?
A) Bundling nursing care
B) Quantifying nursing care
C) Rationing nursing care
D) Increasing demand for nursing care
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Answer: B
Explanation: A) Quantifying nursing care will help control costs by ensuring that clients pay only for the exact level of nursing care they require. It will also provide useful data that allows facilities and providers to better track the cost effectiveness of various nursing actions, as well as allocate nursing resources in the most efficient way possible. Bundling nursing care does not allow facilities to track the cost of nursing actions. Rationing nursing care is related to supply and demand, not tracking nursing actions. Increasing the demand for nursing care would not facilitate more efficient tracking of nursing actions.
433
The movement from a retrospective payment system to a prospective payment system using a diagnosis-related group may have what unintentional consequence for hospitals trying to contain their costs?
A) Hospitals are now admitting more clients than previously.
B) Patients are sent home from the hospital as soon as possible.
C) Physicians order as many tests as needed to correctly diagnose the client's condition.
D) Nurses are encouraged to follow safety protocols to reduce complications.
Answer: B
Explanation: A) The movement to a prospective payment system has resulted in healthcare agencies choosing to withhold borderline necessary tests and procedures, not order as many tests as needed to correctly diagnose the client's condition. It has also shortened hospital stays, so clients are sent home from the hospital as soon as possible to avoid the expenditures a prolonged stay generates. Hospitals are now admitting fewer clients, not more clients. Nurses are encouraged to follow safety protocols regardless of the payment system.
434
The nurse delegates vital signs and daily weights of assigned clients to the unlicensed assistive personnel (UAP) on duty. Which is the reason for the nurse to assess each client throughout the shift?
A) The UAP cannot report to the next shift.
B) The UAP is not trustworthy.
C) The nurse maintains the authority to care for the clients.
D) The nurse remains accountable for the clients' care.
Answer: D
Explanation: A) The nurse remains accountable for the care of clients during delegation to the UAP. The UAP may be untrustworthy, but the reason the nurse checks on the clients is because the accountability belongs to the nurse. The nurse could take a report from the UAP and report that to the next shift. The nurse transfers the authority for the delegated care to the UAP.
435
A postoperative client is transferred to the medical-surgical unit from the intensive care unit (ICU). The client asks the assigned nurse why unlicensed assistive personnel (UAP) help with range-of-motion exercises. Which is the best response by the nurse?
A) "Your condition has improved, so I delegated that part of your care to the UAP."
B) "You do not need me to ambulate you."
C) "The charge nurse made the decision to have the UAP assist you when walking."
D) "I assigned all of your care to the UAP."
Answer: A
Explanation: A) An assignment of care is made to a qualified individual (the RN), who then may delegate parts of that care to a UAP. The nurse would not assign care to the UAP, but rather, delegate certain tasks to the UAP. Saying that the client does not need the nurse is not the best approach; it is better to explain that the client has improved to the point where the UAP can assist with certain tasks. The UAP may be delegated tasks by a nurse assigned to care for the client. The charge nurse does not make the assessment to delegate to the UAP; the RN assigned to the care of the client is the decision maker.
436
The nurse is working on a medical-surgical unit that is short staffed due to a callout. The manager of the unit was unable to replace the nurse, so the extra clients were assigned to the remaining nurses. The manager was able to get the help of unlicensed assistive personnel (UAP) from the house pool to help on the unit. Which action by the nurses would ensure effective care for the client?
A) Delegate vital signs and weights to the UAP.
B) Explain to the manager that care may be compromised if another nurse does not work the shift.
C) Tell the clients their care will be sparse.
D) Assign care of invasive lines to the UAP.
Answer: A
Explanation: A) The nurses would delegate to the UAP tasks such as taking and recording vital signs and weights to ensure that all clients receive appropriate care. UAPs are not assigned care, they are delegated tasks, and nurses should never delegate the task of care of invasive lines to the UAP. The goal for the unit is to meet the needs of the clients; complaining to the manager will not accomplish this. Telling the clients their care will be sparse is inappropriate.
437
) The nurse is caring for several medical-surgical clients. The nurse has delegated skin care of an incontinent client to new unlicensed assistive personnel (UAP) on the unit. Which action by the nurse will improve effectiveness of the client care provided?
A) Ask the client if the care was appropriate.
B) Ask the UAP if the care was given.
C) Demonstrate the appropriate care needed and have the UAP give a return demonstration.
D) Closely observe the UAP each time the care is given.
Answer: C
Explanation: A) The nurse would show the UAP the exact procedure the first time to avoid any confusion and then have the UAP give a return demonstration to ensure the UAP knows how to properly perform the procedure. The nurse would reassess the client's skin later rather than asking the UAP if the task was done. The nurse could possibly alarm the client by asking the client if care was appropriate. Closely observing the UAP each time defeats the purpose of delegation.
438
) The nurse is working on a unit with unlicensed assistive personnel (UAP). One nurse refuses to use the UAP and is consistently leaving nursing tasks for the next shift that have yet to be completed. Which is the most likely reason the nurse is not using the UAP to assist with client care?
A) Avoidance of responsibility
B) Overdependence on others
C) The belief that no one else can perform a task as well as the nurse can
D) The state nurse practice act
Answer: C
Explanation: A) One barrier to delegation is the belief that nobody else is capable of getting the job done for the client. The state nurse practice act would be considered an environmental barrier. The nurse who refuses to delegate care is not being overly dependent. The nurse is accepting too much responsibility rather than too little.
439
The nurse delegated to an unlicensed assistive personnel (UAP) the task of assisting a client with a simple dressing change. The client was formerly able to do the procedure, but because of painful arthritis is now unable to perform the redressing. The UAP has done this procedure before. Which must the nurse emphasize to the UAP?
A) Report to the nurse immediately anything unusual, such as bleeding or infection.
B) The nurse should demonstrate the steps of the procedure.
C) Make the client do most of the procedure and report the expected output.
D) The UAP should do health teaching while performing the procedure.
Answer: A
Explanation: A) The nurse delegated a specific legal task to the UAP, which is within the scope of the UAP's ability. The nurse established the particular parameters outside of which immediate notification is requested. If in pain, the client should not have to do any of the procedure. If the UAP has done the procedure before, the nurse should not need to demonstrate it. Health teaching is outside of the scope of practice for the UAP.
440
) A nurse-supervisor is encouraging nurses to delegate responsibilities whenever possible. Which criteria are used to determine tasks that can be delegated? Select all that apply.
A) Does the delegate have the appropriate skills to perform the task safely?
B) How busy are you?
C) Is the client frequently complaining?
D) Does the task require client education?
E) Is the task unpleasant?
Answer: A, D
Explanation: A) Only tasks that are within the delegate's scope of practice and that the delegate has the skills to perform safely should be delegated. Tasks that require client education should never be delegated. The nurse's busyness may point out the need for delegation but it does not define which tasks may be delegated. The behavior of the client and the unpleasant nature of the task are not criteria for delegation.
441
An experienced delegator is mentoring a newly appointed nurse in the hospital. The new nurse states, "I am hesitant to delegate tasks to unlicensed assistive personnel (UAP) because I am afraid they will not be done correctly." Which response by the experienced delegator is appropriate?
A) Tell her not to delegate any tasks unless she is completely confident.
B) Tell her to clearly identify the task and expectations and then to monitor the delegate's progress.
C) Tell her that delegation often results in a decrease in job satisfaction.
D) Tell her that her job responsibility requires that she do everything herself.
Answer: B
Explanation: A) Although this is a typical concern of inexperienced and insecure delegators, following the delegation guidelines can increase her confidence in the process. The key to retaining control is to clearly identify the task and expectations and then to monitor the delegate's progress and provide feedback. If one is able to delegate some routine tasks to others, then job satisfaction should increase because of increased opportunities. An appropriate environment supports delegation.
442
A staff nurse at a hospital calls a long-term care facility that has just received transfer of care for a client. The hospital nurse reports the physician's medication orders to a nurse at the receiving facility. The hospital nurse does not have prescribing privileges. What is the responsibility of the nurse at the receiving facility in order to reduce the fear of liability?
A) Withhold medications until the facility's physician can assess the new client
B) Administer medications to the client immediately
C) Verify the order with the prescribing physician
D) Submit the medication order to the on-site pharmacy as soon as possible
Answer: C
Explanation: A) If the nurse calling the long-term care facility does not have prescribing privileges, then the nurse at the receiving facility must verify the order with the prescribing physician. Administering medications immediately or submitting the order to the pharmacy without verification would not reduce liability. Withholding medications until the facility's physician can assess the new client would also not reduce liability.
443
A nursing supervisor has been told to ensure that the hospital's new electronic records system is properly implemented on the nursing unit. Which actions by the supervisor are the best use of exercising the managerial role? Select all that apply.
A) Creating a "buddy" system that pairs staff members who are more technologically comfortable with staff members who may require more assistance with the new system
B) Providing regular training sessions in the new system
C) Informing staff that the new system is optional
D) Establishing a regular spot check of each staff member's effective use of the system
E) Continuing to use paper records until the staff is completely comfortable with the new system
Answer: A, B, D
Explanation: A) The manager's role includes choosing the means by which to achieve goals, assigning and coordinating tasks and developing and motivating staff, and evaluating outcomes and providing feedback. The manager should not undermine the organizational goals and objectives.
444
The nurse manager is interested in initiating self-scheduling on the medical-surgical unit. Which are stages of the planning process for the initiative that the nurse manager will use? Select all that apply.
A) Establish objectives (goals).
B) Evaluate the present situation and predict future trends and events.
C) Formulate a planning statement (means).
D) Coordinate the work to be done.
E) Convert the plan into an action statement
Answer: A, B, C, E
Explanation: A) The four steps of the planning process include establishing objectives (goals), evaluating the present situation and predicting future trends and events, formulating a planning statement (means), and converting the plan into an action statement. Coordination is part of organization, not planning.
445
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The nursing supervisor is asked to help manage the switch from paper to electronic records.Which standard managerial steps will the nursing supervisor take to initiate this process? Select all that apply.
A) Planning
B) Experimenting
C) Organizing
D) Criticizing
E) Synthesizing
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Answer: A, C
Explanation: A) The nurse manager plans and develops specific goals and objectives for his or her area of responsibility. Organizing is the process of coordinating the work to be done. Experimenting, criticizing, and synthesizing, although they may be done by managers, are not standard managerial functions
446
A supervisor on a medical-surgical unit excels at scheduling staff and allocating resources. However, when new policies are being implemented, the supervisor has great difficulty getting staff cooperation. Based on this data, why is the supervisor considered a manager and not a leader?
A) A leader clarifies the organizational structure.
B) A leader uses interpersonal skills to accomplish goals.
C) A leader always assigns and coordinates tasks.
D) A leader must use contingency planning.
Answer: B
Explanation: A) Leaders use interpersonal skills to influence others to accomplish specific goals, and this supervisor has trouble influencing others. Managers are more apt to clarify the organizational structure, assign and coordinate tasks, and use contingency planning.
447
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The emergency department staff is overwhelmed when multiple victims arrive from an explosion at a downtown factory. What leadership style would be most beneficial for the charge nurse to adopt in this situation to most efficiently provide nursing care to the incoming victims?
A) Autocratic
B) Democratic
C) Laissez-faire
D) Bureaucratic
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Answer: A
Explanation: A) An autocratic leader is most effective when urgent decisions must be made in a critical situation. The autocratic leader gives orders and directions to the group to most efficiently care for the victims. A democratic leader encourages group discussion and decision making, which is not appropriate for this situation. A laissez-faire leader takes a hands-off approach, which may cause a lack of cooperation and coordination. A bureaucratic leader relies on rules, policies, and procedures to direct the work.
448
A nurse manager has created a culture of empowerment among the nursing staff. The nursing staff feels that they have the information, support, and resources to perform their tasks efficiently and effectively, and they also have opportunities for advancement, continued education, and input into nursing policies. What are the consequences of this type of environment?
A) The nurses will feel the need to find jobs elsewhere.
B) The nurses will be more committed to the institution.
C) The nurses will work independently without help from others.
D) The nurses will effectively avoid conflict.
Answer: B
Explanation: A) Empowered employees will be more committed to the institution, more effective in their roles, and more confident in their abilities. They would usually remain in their current position than try to find a job elsewhere. An empowered team of nurses will work together more effectively, not work independently. An empowered team of nurses will not necessarily avoid conflict, but they will know how to manage conflict more effectively.
449
A local health system implemented a number of health promotion policies and plans to prioritize health problems. The system must now evaluate the effectiveness of the interventions. Which groups are stakeholders in this initiative and would be involved in the evaluation process?
A) Only consumers who were directly affected by the services provided
B) Consumers, community leaders, and politicians
C) Only hospital and clinic personnel who administered healthcare needs
D) Healthcare providers employed by other health systems
Answer: B
Explanation: A) Community leaders, politicians, and consumers all would be stakeholders and would be included in the evaluation process. Healthcare providers employed by other health systems would not be stakeholders in this initiative and would not need to be included in the evaluation process. Because policy changes are made by the health system, the hospital and clinic personnel employed there would not evaluate the effectiveness of policy without participation by the community. Consumers are part of the process, but would not be the only evaluation group.
450
Which types of programs can receive accreditation from the National League of Nursing (NLN)? Select all that apply.
A) Bachelor of Science in Nursing (BSN) programs
B) Licensed Vocational Nursing (LVN) programs
C) Medical Assisting programs
D) Licensed Practical Nursing (LPN) programs
E) Dental Assisting programs
Answer: A, B, D
Explanation: A) The NLN accredits nursing programs at all levels, including BSN, LPN, and LVN programs. Medical Assisting and Dental Assisting programs would not be eligible for NLN accreditation
451
A nursing student would like to learn more about developing professional behavior. Which action should the student take in order to access information that may be useful in developing professional demeanor?
A) Join the America Nurses Association (ANA).
B) Join the National Student Nurses Association (NSNA).
C) Read the Nurse Practice Act.
D) Use the Internet to obtain information.
Answer: B
Explanation: A) The NSNA is an organization specifically for student nurses with a goal of assisting the student to foster their professional development. Nurse practice acts do need to be read by students, but they denote laws, not professionalism. The ANA is for members practicing nursing, not students, although students may join. The NSNA focuses on students and is a better resource. The Internet is good for obtaining information and for networking but is not necessarily a help to the student who wishes to increase professionalism
452
An older adult client experiences an extended hospitalization due to a chronic illness. The client states to the nurse, "I don't know how I can pay for this hospital stay and afford all of the new medication that I have been prescribed." Which response by the nurse is the most appropriate?
A) "I'll have someone from the business office come and talk to you about your bill."
B) "You need to focus on recovering and stop worrying about money."
C) "Much of your care will be covered by Medicare."
D) "Don't worry. I'm sure everything will work out okay."
Answer: C
Explanation: A) Medicare is a federally funded health insurance program for individuals age 65 and older. Coverage can include both hospital, medical, and pharmacy costs. However, it does not cover all medical costs. Ignoring the client's concerns by telling him not to worry is not therapeutic communication and does little, if anything, to confront the client's concerns. Giving the concern to the business office is merely "passing the buck."
453
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A student nurse will be attending clinicals at the local health department. When preparing for the clinical experience, the student researches programs offered by health departments. Which programs did the student most likely find during the research? Select all that apply.
A) Injury prevention campaigns
B) Lead poisoning prevention efforts
C) Nutritional programs
D) Disease monitoring efforts
E) Workplace safety inspections
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Answer: A, B, C, D
Explanation: A) Local health departments oversee a variety of health policies and the respective regulations. Typical programs include injury prevention campaigns; lead poisoning prevention efforts; and making safety equipment available to families at no cost. Local departments of health usually administer the Women, Infants, and Children (WIC) supplemental nutrition program. They are also often responsible for developing and enforcing city-wide health codes and for disease monitoring. The Occupational Safety and Health Administration (OSHA) is a federal agency that works to ensure the health and safety of Americans in the workplace
454
Which regulatory agency ensures the health and safety of Americans in the workplace?
A) Department of Health and Human Services (DHHS)
B) National Institutes of Health (NIH)
C) Occupational Safety and Health Administration (OSHA)
D) Centers for Medicare and Medicaid Services (CMS)
Answer: C
Explanation: A) OSHA works to ensure the health and safety of Americans in the workplace. The DHHS is the federal government's principal agency for the protection of the health of all Americans and the provision of essential human services for those least able to care for themselves. The NIH is a branch of the DHHS that is responsible for health research and the provision of health-related information. The CMS is responsible for healthcare financing.
455
Which organization promotes excellence in all levels of nursing education?
A) National League for Nursing (NLN)
B) National Student Nurses Association (NSNA)
C) American Nurses Association (ANA)
D) American Association of Colleges of Nursing (AACN)
Answer: A
Explanation: A) Part of the mission of the NLN is to promote excellence in nursing education to build a strong and diverse nursing workforce. The NSNA is a nonprofit organization that mentors nursing students who are preparing for initial licensing as a registered nurse. The ANA fosters high standards of nursing practice, promotes the rights of nurses in the workplace, projects a positive and realistic view of nursing, and lobbies Congress and regulatory agencies on healthcare issues affecting nurses and the public. The AACN is the national voice for America's baccalaureate and graduate nursing education programs.
456
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) When a law related to public health policy is passed, what type of agency of the federal or state government is responsible for administering it?
A) A local branch agency
B) A legislative branch agency
C) An executive branch agency
D) A judicial branch agency
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Answer: C
Explanation: A) Once a law related to health policy has been passed, an executive branch agency of the federal or state government, such as the Centers for Disease Control and Prevention (CDC), is responsible for administering it. Legislative and judicial branch agencies are not involved in this area. Federal or state agencies, not local agencies, have this responsibility.
457
What action can a nursing student take to comply with nurse practice acts and remain accountable for knowing the legal nursing scope of practice in their state?
A) Become engaged in organizational quality improvement projects.
B) Obtain current licensure.
C) Join the American Nurses Association (ANA).
D) Become accredited.
Answer: B
Explanation: A) Current licensure is required for practice as a nurse as part of the nurse practice acts. Through licensure, nurses are held accountable for knowing the legal nursing scope of practice in their state and what actions could place their licensure status in jeopardy, as well as all regulations that accompany the nurse practice act. Nurse practice acts do not require membership in the ANA. Participation in quality improvement projects will not help the student know the legal nursing scope of practice. Healthcare organizations, not nurses, can become accredited.
458
The nurse is working for a healthcare organization that is going through the reaccreditation process. What action can the nurse take to help the organization be successful in the reaccreditation process?
A) Write position statements related to current events that affect the nursing profession.
B) Influence change by working with public officials at the local, community, state, and national levels.
C) Understand how healthcare policy affects patients, their own practice, and their organization.
D) Facilitate the use of nursing procedures that are current and evidence-based.
Answer: D
Explanation: A) The nurse's role in The Joint Commission accreditation process may include helping to develop, revise, or facilitate use of policies and procedures for nursing practice that are current and evidence-based. Although working with public officials and understanding healthcare policy are important roles of nurses related to health policy, they do not directly affect accreditation. Writing position statements is a responsibility of the ANA Board of Directors.
459
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Which type of health insurance plan requires the participant to select a primary care provider?
A) Health maintenance organization (HMO)
B) Preferred-provider organization (PPO)
C) Point-of-service (POS)
D) Indemnity
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Answer: A
Explanation: A) Of the four main types of private health insurance plans, the only one that requires the participant to select a primary care provider is the health maintenance organization (HMO) plan.
460
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) The nurse is providing care to a pregnant client who will undergo chorionic villus sampling. The client is currently 10 weeks pregnant. When teaching the client about this genetic testing, which layer of the embryonic membrane will the nurse say is tested during this procedure?
A) Chorion
B) Amnion
C) Ectoderm
D) Endometrium
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Answer: A
Explanation: A) The chorion is the outermost embryonic membrane and develops into chorionic villi, which can be used for early genetic testing of the embryo at 10 to 11 weeks' gestation by chorionic villus sampling. The endometrium is the lining of the uterus and will not be used for genetic testing of the embryo. The ectoderm is a germ layer and will develop into specific structures within the developing fetus. The amnion will develop into amniotic fluid, which can also be sampled for genetic testing but may not be developed by 8 weeks' gestation.
461
The nurse is instructing a client who is at 10 weeks' gestation on avoiding substance abuse. Which is the rationale for why substances of abuse should be avoided during pregnancy?
A) Interferes with hormone excretion of the fetus
B) Facilitates the transfer of viruses and other diseases into the developing fetus
C) Passes into the developing fetus through the placenta very easily
D) Stops the synthesis of protein in the developing fetus
Answer: C
Explanation: A) Substances of abuse pass from the mother to the fetus through the placenta via simple diffusion. These substances have adverse effects on the developing fetus. Substances of abuse do not interfere with hormone excretion of the fetus or stop the synthesis of protein in the fetus. They do not facilitate the transfer of viruses and other diseases into the developing fetus.
462
) A client pregnant with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. When responding to the client, which should the nurse take into consideration?
A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy.
B) This is a normal reaction by fathers that is seen in the third trimester of pregnancy.
C) This is a normal reaction by fathers that is seen in the first trimester of pregnancy.
D) This is an atypical reaction of the father to pregnancy that should be further examined.
Answer: A
Explanation: A) Pregnancy produces psychological changes in the mother and father of the child. A reaction seen in the father during the second trimester of pregnancy is a renewed interest in hobbies or activities outside of the family and is usually a sign of stress. This behavior is not typical in the first or third trimesters and is not an atypical reaction that should be further examined.
463
A pregnant adolescent client asks for information about the pregnancy and the baby because she cannot afford prenatal care. Which action by the nurse is the most appropriate?
A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery.
B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery.
C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance.
D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.
Answer: A
Explanation: A) Poverty and low education levels are associated with adolescent pregnancy. The nurse should support the client by providing information on resources to assist with medical care during the pregnancy and after delivery. The nurse should not instruct the client on all aspects of the pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to the client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell the client that the baby's father is responsible for her medical care; these actions do not address the client's needs.
464
An adolescent client at 34 weeks' gestation states to the nurse, "I am stressed out about becoming a mother. I hope that I can get back to my normal day to day activities after the baby is born, like hanging out with friends and studying." If the nurse wants to assess whether the client is performing normal developmental tasks for this stage of pregnancy, which question by the nurse is the most appropriate?
A) "Are your friends excited about the baby coming and planning a shower for you?"
B) "Are you prepared to delay some of your own needs and desires for your baby?"
C) "Do you miss going out with your friends on the weekends?"
D) "Have you been able to get enough rest while keeping up with your studies?"
Answer: B
Explanation: A) One developmental task for the mother is learning to give of oneself on behalf of the child. The statement by this client that she wants to get back to her normal activities indicates that she is still self-focused. The nurse should assess the client's preparedness for putting aside her own wants and needs temporarily for the good of her child. The nurse should not focus on the client's social life and friends because these are not developmental tasks associated with the pregnancy.
465
) A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. Based on this data, which conclusion by the nurse is the most appropriate?
A) The mother is at 8 to 12 weeks' gestation.
B) The mother is over 16 weeks' gestation.
C) The mother is at 4 to 8 weeks' gestation.
D) The mother is at least 20 weeks' gestation.
Answer: A
Explanation: A) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because the Doppler device detected fetal heartbeat. The mother will have likely already heard the heartbeat at least once before 16 to 20 weeks' gestation if her primary care provider has access to a Doppler device.
466
The nurse is providing care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy. Which actions by the nurse are appropriate based on this data? Select all that apply.
A) Notify the healthcare provider that the client is experiencing hyperemesis gravidarum.
B) Educate the client to notify the healthcare provider if she vomits once per day.
C) Suggest the client use acupressure to pressure points on the wrist.
D) Teach the client that ginger may relieve her symptoms.
E) Caution the client against using over-the-counter medications such as over-the-counter antihistamines.
Answer: C, D
Explanation: A) Nausea and vomiting is a common experience during the first trimester of pregnancy. Acupressure and ginger are two complementary therapies that the nurse can suggest to the client to relieve the symptoms. There is no evidence that the client is experiencing hyperemesis gravidarum. The client should be taught to notify the healthcare provider if vomiting occurs more than once a day. Over-the-counter antihistamines are safe to use during pregnancy to decrease the occurrence of nausea and vomiting if recommended by the doctor.
467
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following?
A) Drink a glass of water every time nausea occurs.
B) Take a multivitamin each day.
C) Take over-the-counter Benadryl for the nausea.
D) Eat a snack any time nausea occurs.
Answer: B
Explanation: A) Multivitamins may reduce the nausea associated with the first trimester of pregnancy. The nurse should not instruct the client to drink a glass of water every time nausea occurs because this could lead to the ingestion of high quantities of water. The nurse should not instruct the client to eat a snack any time nausea occurs, as this could lead to higher than needed calorie intake and inappropriate weight gain, and it also will not likely help the nausea significantly. The nurse should also not instruct the client to ingest an over-the-counter medication without discussing this with her physician.
468
) A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen, a pregnant client in her second trimester has a hemoglobin of 10 g/dL. The client confirms fatigue, but otherwise feels fine. Which action by the nurse is the priority when providing care to this client?
A) Tell the client to rest any time she feels fatigued.
B) Recommend the client add supplemental iron to her diet.
C) Ask the client to return in 2 months for a repeat check of her hemoglobin.
D) Order a screening for sickle cell anemia.
Answer: B
Explanation: A) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low hemoglobin during pregnancy suggests an inadequate intake of dietary iron as the probable cause of her anemia. Given that the client's anemia is likely from iron deficiency, the nurse needs to emphasize the importance of increased iron supplementation. A screening for sickle cell anemia is not indicated given the information presented. The client should return in 1 month for a recheck of her hemoglobin levels; if improvement is not seen, then further evaluation is indicated. Although adequate rest is important, it does not address the client's physiologic iron deficiency that is causing the fatigue.
469
The nurse is providing care to a client whose last menstrual period was 6 weeks ago. The client believes she is pregnant. Which diagnostic test does the nurse anticipate in order to confirm the pregnancy?
A) Serum or urine human chorionic gonadotropin (hCG)
B) Fetal heartbeat by Doppler
C) Fetal heartbeat by fetoscope
D) Fetal movement
Answer: A
Explanation: A) The most commonly used assay for pregnancy diagnosis is measuring the beta subunit of hCG in either urine or serum. hCG is detectable in more than 97% of clients. A fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may experience movement subjectively, called quickening, around this same time.
470
The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant. Which response by the nurse is appropriate?
A) "Do you think your wife got pregnant on purpose, without your consent?"
B) "Have you considered giving the baby up for adoption?"
C) "Tell me more about why you feel this way."
D) "Every husband has these feelings, and many times they never go away."
Answer: C
Explanation: A) The nurse needs to include the care of the father when providing care to a pregnant client. The husband is expressing uncertainty about his ability to be a father and regrets the pregnancy. The best response by the nurse is to explore the father's feelings. The nurse should not minimize the husband's feelings by stating every husband has these feelings. It is inappropriate for the nurse to say that the feelings may never go away. The nurse should not suggest that the baby be given up for adoption or that the client became pregnant on purpose
471
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The nurse is reviewing the immunization record for a client who just learned she is pregnant. Which vaccine is not safe to give during pregnancy?
A) Pertussis
B) Annual influenza
C) Rubella
D) Tetanus
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Answer: C
Explanation: A) Rubella vaccine should never be given to pregnant women (or women trying to conceive) because the vaccine contains the attenuated live virus, which has teratogenic effects on the developing fetus. Pertussis, tetanus, and annual influenza vaccines can safely be given in pregnancy. Safe vaccine recommendations for pregnant women are available from the Centers for Disease Control and Prevention website (http://www.cdc.gov).
472
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During which phase of the ovulatory cycle does the ovum get fertilized?
A) Follicular phase
B) Luteal phase
C) Proliferative phase
D) Secretory phase
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Answer: B
Explanation: A) The ovum can be fertilized as it moves through the fallopian tube, which occurs after the graafian follicle ruptures. The rupture of the graafian follicle begins the luteal phase. The ovum is still encapsulated in the graafian follicle in the follicular phase, and it cannot be penetrated by sperm. The proliferative phase and secretory phase are phases of the menstrual cycle, not the ovulatory cycle.
473
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply.
A) Avoid shrimp, salmon, and catfish because these have higher mercury levels.
B) Eat up to 12 ounces a week of a variety of fish and shellfish.
C) Do not eat more than 6 ounces per week of albacore tuna.
D) Eat plenty of fish such as king mackerel while pregnant.
E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
Answer: B, C
Explanation: A) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system of the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct the client to eat up to 12 ounces a week of a variety of fish and shellfish. The nurse should advise the client to eat no more than 6 ounces of albacore tuna each week because it has more mercury than other canned tuna. King mackerel should be avoided because it contains high levels of mercury. The nurse should not suggest that the client consume a complete vegetarian diet because this could lead to other nutritional deficiencies. The nurse should encourage the client to consume shrimp, salmon, and catfish, because these fish have the least amount of mercury.
474
A client at 16 weeks' gestation is diagnosed with tuberculosis (TB). Which statement by the nurse is appropriate when instructing the client regarding the needs for both the client and fetus?
A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)."
B) "Your contact with the baby will be limited for several months after delivery."
C) "You will not be able to breastfeed your baby because of this diagnosis."
D) "You are free to have contact with anyone as TB is not contagious when diagnosed during
Answer: A
Explanation: A) When teaching a pregnant client diagnosed with TB, the nurse will include information regarding medication administration. Isoniazid, which does cross the placenta but most studies show is not teratogenic, is often the drug of choice to treat TB during pregnancy. When taking isoniazid, the client will also need to take pyridoxine. If TB is active at delivery, the newborn should not have direct contact with the mother while she is infectious. This is not likely going to be the case, as the client is diagnosed early in the pregnancy. If maternal TB is inactive, the mother may breastfeed and care for her infant. Extra rest and limited contact with others are required until the disease becomes inactive.
475
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A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data?
A) Ineffective Breastfeeding
B) Dysfunctional Family Processes
C) Nausea
D) Fatigue
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Answer: C
Explanation: A) Of the three physiologic complaints, the one that has the highest priority is nausea because it could directly impact the developing fetus. Breast tenderness does not mean that the client will experience ineffective breastfeeding. Fatigue is a common symptom of pregnancy and would not negatively impact the developing fetus. The husband being upset with the client's complaints does not necessarily mean that she and her husband have dysfunctional family processes.
during antepartum.
476
The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate?
A) Provide dietary instruction instead to ensure the client does not gain excessive weight.
B) Tell the client to just perform the exercises that don't require her to reach over her head.
C) Provide alternative activities to do instead of exercise.
D) Assure the client that reaching over the head will not harm the baby.
Answer: D
Explanation: A) Clients of European, African, and Mexican descent may believe that reaching over the head during pregnancy can harm the baby. The nurse should assure the client that this is not accurate. Providing activities to do instead of exercise or telling the client to avoid the exercises that require her to reach over her head will not address the misconception that reaching over the head will harm the baby. Dietary instruction during pregnancy is important to ensure a healthy weight gain for a healthy baby, not to ensure the client does not gain excessive weight because of lack of exercise.
477
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates appropriate understanding of the information presented?
A) "The test has to be done before the 14th week of pregnancy."
B) "If the test determines our baby has Down syndrome, we will not need to take childbirth classes."
C) "It is not unusual for amniocentesis to misdiagnose a problem with the baby."
D) "The results of the amniocentesis will take up to 2 weeks."
Answer: D
Explanation: A) For couples having an amniocentesis, the first few months of pregnancy can be difficult because the test cannot be performed until the 14th week of pregnancy, and not before. The results of the amniocentesis will not be available for up to 2 weeks, which is evidence that instruction regarding the test has been understood by the client and spouse. Childbirth classes are important in promoting adaptation to the event of childbirth for expectant couples of any age or situation. The results of an amniocentesis are 99% accurate in diagnosing genetic abnormalities.
478
The nurse is providing care to a pregnant client who is experiencing ptyalism. Which will the nurse include in the plan of care for this client?
A) Use a cool-mist vaporizer
B) Suck on hard candy
C) Avoid use of nasal sprays and decongestants
D) Use low-sodium antacids
Answer: B
Explanation: A) Ptyalism is excessive, often bitter salivation that can occur during pregnancy. Appropriate interventions for this client include using astringent mouthwashes, chewing gum, or sucking on hard candy. A cool-mist vaporizer and avoiding nasal sprays and decongestants are appropriate interventions for nasal stuffiness and nosebleed (epistaxis). The use of low-sodium antacids is appropriate for pyrosis, or heartburn.
479
The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client?
A) Perform the pelvic rock exercise only in the standing position.
B) Exercise in the supine position throughout the pregnancy.
C) Perform the pelvic rock exercise while in the hands and knees position.
D) Soak in a hot tub for approximately 30 minutes after exercise.
Answer: A
Explanation: A) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain, as it strengthens the abdominal muscles. The client with a history of back pain should be instructed to perform the exercise in the standing position only. Doing the exercise on the hands and knees may aggravate back strain and cause pain. Pregnant clients should be instructed to avoid exercising in the supine position after the first trimester because it could hinder uterine blood flow and harm the fetus. Pregnant clients should be instructed to avoid hot tubs because of the possible teratogenic effects of hyperthermia on the developing fetus.
480
The nurse is providing care to a client with a history of rheumatoid arthritis (RA) who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply.
A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy
B) Monitoring the client for anemia due to salicylate therapy
C) Suggesting the client begin supplemental pyridoxine
D) Educating the client that medication therapy may be discontinued due to remission
E) Teaching the client that RA may be contracted by the fetus during pregnancy
Answer: B, D
Explanation: A) When providing care to a client with RA during pregnancy, the nurse will monitor the client for anemia due to salicylate therapy and educate the client that medication therapy may be discontinued if the client experiences remission during the pregnancy. Salicylate therapy is associated with prolonged gestation and labor. Supplemental pyridoxine is required for clients being treated with isoniazid for TB during pregnancy. RA cannot be contracted by the fetus during pregnancy.
481
The nurse is caring for a pregnant client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, which medication prescription does the nurse anticipate?
A) IV corticosteroid (e.g., prednisone)
B) Oral pseudoephedrine (e.g., Sudafed)
C) Inhaled beta2-agonist (e.g., albuterol)
D) Oral acetylsalicylic acid (e.g., aspirin)
Answer: C
Explanation: A) Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations during pregnancy. Steroids, decongestants such as pseudoephedrine, and aspirin should be avoided in pregnancy because of potential harmful effects to the fetus.
482
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Which pregnant client would have the greatest need for a nutritional assessment and individualized meal plan?
A) A client who is lactose intolerant
B) A client who is vegetarian
C) A client who requires a Kosher diet
D) A client with anorexia nervosa
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Answer: D
Explanation: A) Although all of these clients will need special considerations related to diet and nutritional requirements, the client with anorexia nervosa, an eating disorder, is at highest risk for inadequate nutrition. When a pregnant woman has an eating disorder, education and individualized meal plans can help the patient increase her dietary intake while maintaining a sense of control.
483
The nurse is caring for a 14-year-old client who is pregnant. What will the nurse need to consider that may affect this client more than older adolescents?
A) The client may be more concerned about modesty.
B) The client may be more concerned with state marriage laws.
C) The client may be more concerned about parents finding out about the pregnancy.
D) The client may be more concerned about finding a support person.
Answer: A
Explanation: A) A younger client may be more concerned about modesty than older clients, especially as her body changes and grows rapidly. Older adolescents who are pregnant may be more concerned about state marriage laws, parents finding out about the pregnancy, and finding a support person. Younger clients are more likely to involve parents in the early stages of pregnancy for both emotional and financial support.
484
The nurse is caring for a 36-year-old pregnant woman. She has two children, ages 15 and 13, from a previous marriage, and this is her first child from her second marriage. The client has indicated that her two older children seem very upset by her pregnancy and have been increasingly belligerent the closer she gets to delivery. What can the nurse say to support this family?
A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to."
B) "You could tell your older children that the stress and anxiety that comes with a new baby will help improve your family relationships."
C) "They are probably just embarrassed because you are pregnant. They'll get over it once you have the baby."
D) "Your older children probably just want to know what their new roles will be once the baby is born. You should tell them what their responsibilities will be in caring for the baby."
Answer: A
Explanation: A) Adolescent children, especially children from a previous marriage, may feel jealous that the new baby will take all the attention of the parent or fear that they will be asked to contribute to the newborn's care. The nurse should help the mother understand these feelings and encourage the mother to address these feelings with her older children. Telling the mother that the older children are just embarrassed and will get over it is inappropriate. Encouraging the mother to give newborn care responsibilities to the older children may make the issue worse. Discussing the role of stress and anxiety in improving relationships is more appropriate for a spouse, not older children.
485
) The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse?
A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix."
C) "What did you expect? You've only had contractions for a few hours. Labor takes time."
D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
Answer: D
Answer: D
Explanation: A) Cervical effacement must be nearly complete before cervical dilation takes place in primiparas. This is why the labor and birth of a first baby usually take much more time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.
486
During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse?
A) Massage the fundus.
B) Turn the client onto the left side.
C) Place the bed in the Trendelenburg position.
D) Continue to monitor.
Answer: D
Explanation: A) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.
487
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented?
A) "During labor, the nurse will verify that my contractions are strong but not too close together."
B) "During labor, the nurse will look at the color and amount of bloody show that I have."
C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound."
D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."
Answer: C
Explanation: A) During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound unless complications are present. This is the statement the client should make to prove that education was successful. The nurse will also monitor contractions, bloody show, and the cervix, but these assessments do not monitor the baby's condition.
488
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A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time?
A) Health-Seeking Behaviors
B) Fear
C) Anxiety
D) Acute Pain
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Answer: D
Explanation: A) Many clients experience perineal trauma during the childbirth process, which causes acute pain in the fourth stage of labor. Therefore, Acute Pain is a more appropriate nursing diagnosis related to this condition than Fear or Anxiety. The diagnosis of Health-Seeking Behaviors does not address the client experiencing perineal trauma during labor.
489
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate?
A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured
B) Encouraging the client to void every 1-2 hours
C) Assessing fetal heart rate every 5 minutes
D) Administering antibiotics for a positive group beta strep
Answer: C
Explanation: A) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 5 minutes or after every contraction. Assessing temperature every 1 to 2 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
490
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse?
A) Notifying the healthcare provider that birth is imminent
B) Changing the client's position in bed
C) Beginning continuous fetal heart rate monitoring
D) Administering oxygen at 2 liters per minute
Answer: C
Explanation: A) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.
491
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate?
A) Documenting the fetal heart rate
B) Preparing for imminent delivery
C) Applying oxygen via mask at 10 liters per minute
D) Assisting the client into the Fowler position
Answer: A
Explanation: A) The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The client does not need to be assisted into the Fowler position.
492
A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply.
A) The contractions do not have a regular pattern.
B) Her cervix has dilated 2 cm over the 2 hours of observation.
C) The frequency and intensity of the contractions have stayed about the same.
D) Walking seems to increase the strength of the contractions.
E) The contractions are mostly in her abdomen.
Answer: A, C, E
Explanation: A) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to the front, and the fact that activity does not increase contraction intensity.
493
During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate?
A) This is evidence of incomplete expulsion of the placenta.
B) The client has a full bladder.
C) This is a normal reaction to the ending of the physical exertion of labor.
D) The client has a fever from a postpartum infection
Answer: C
Explanation: A) Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
494
A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate?
A) The cervix is favorable for a normal vaginal delivery.
B) The cervix is unfavorable and induction of labor may be necessary.
C) The cervix is unfavorable and a cesarean section may be necessary.
D) The cervix is favorable and labor has been successfully induced.
Answer: B
Explanation: A) A Bishop score less than 6 indicates that the cervix is unfavorable. When a pregnant woman at or near term has an unfavorable cervix, induction of labor may be necessary for medical or obstetric reasons. A Bishop score less than 6 does not indicate that a cesarean section may be necessary
495
The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client?
A) Encourage the client to avoid seeing and holding the baby.
B) Encourage the client to see and hold the baby.
C) Encourage the client to have the adoptive parents present for the birth.
D) Encourage the client to sign the adoption papers as soon as possible after the birth
Answer: B
Explanation: A) The adolescent who is planning to give up her baby for adoption should be given the option of seeing and holding her baby. This facilitates the grieving process. However, seeing or holding the newborn should be her choice. The nurse should not discourage the adolescent from seeing her baby and should not encourage the adolescent to sign adoption papers as soon as possible after the birth. Because of privacy concerns, the nurse should not encourage the adolescent to have the adoptive parents present for the birth except for special circumstances as determined by the client, not the nurse.
496
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The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications?
A) A healthy 38-year-old woman
B) A 24-year-old woman with asthma
C) A 36-year-old woman with diabetes
D) A 31-year-old woman with hypertension
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Answer: C
Explanation: A) Women over the age of 35 have an increased risk for complications during labor and delivery, especially when the woman already has preexisting medical conditions such as hypertension or diabetes. However, risks are much lower for women under the age of 35 or women over the age of 35 who do not have preexisting medication conditions.
497
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During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up?
A) Moderate lochia rubra
B) Steady trickle of blood
C) Fundus at the umbilical level
D) Firm fundus
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Answer: B
Explanation: A) The steady trickle of blood could indicate a laceration in the birth canal and should be reported to the healthcare provider for follow-up. A firm fundus is a desired finding and is considered normal. Six hours after birth, the fundus at the umbilicus would not be a concern. Moderate lochia rubra is considered a normal finding.
498
The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply.
A) Assess for any assistance required during breastfeeding.
B) Ask if there are any specific customs the client wants to follow.
C) Assess for any specific foods or fluids to hasten recovery.
D) Limit client visitors to the immediate family.
E) Restrict interactions with the client.
Answer: A, B, C
Explanation: A) When providing postpartum care to a client of a different culture, the nurse should assess for any specific customs the client wants to follow, if there are any foods or fluids in the culture that are believed to hasten recovery, and if the client requires any assistance during breastfeeding. Restricting visitors would not support the postpartum client's needs. Restricting interactions would not support the client's physiologic or psychologic needs.
499
A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on a scale of 0-10. The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis?
A) Acute Pain related to perineal trauma
B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
C) Deficient Knowledge related to birth of first child
D) Readiness for Enhanced Family Coping related to partner involvement
Answer: A
Explanation: A) The client has a pain level of 6, so treating pain is a high priority for this client. Pain could contribute to nausea and a decreased desire to drink fluids, so treating the pain could decrease the risk for deficient fluid volume. Actual diagnoses, such as Acute Pain, are almost always higher priority than Risk diagnoses. Although the nursing diagnoses of Readiness for Enhanced Family Coping and Deficient Knowledge fit, they are a lower priority than treating pain.
500
The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply.
A) Encourage the use of breathing, relaxation, and distraction.
B) Encourage deep breathing and coughing every 2 to 4 hours.
C) Encourage to ambulate to the bathroom to void.
D) Discourage leg exercises.
E) Withhold all analgesics.
A, B
Explanation: A) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients. Encouraging the client to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
501
) A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply.
A) Washing the area with soap and water every day
B) Tightening the buttocks before sitting
C) Changing peripads daily
D) Performing leg scissor kicks several times a day
E) Increasing the intake of meat, cheese, fish, eggs, and nuts
Answer: B, E
Explanation: A) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy. This amino acid is present in meat, cheese, fish, eggs, and nuts. The nurse should instruct the client to tighten the buttocks before sitting to reduce the pain. The client should wash the area daily and the peripad should be changed four times a day to decrease the risk of infection, not pain. Performing leg scissor kick exercises would put strain on the incision site and should not be done.
502
When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client?
A) Notify the client's midwife of this condition.
B) Ask another nurse to assess the client to verify the findings.
C) Ask the client to void and then reassess fundal height.
D) Perform a straight catheterization on the client and then reassess fundal height.
Answer: C
Explanation: A) The cause of a distended fundus in a recently delivered woman is likely due to a distended bladder causing a temporary upward displacement of the uterus. Having the woman empty her bladder and then reassessing fundal height is the priority action for the nurse to take at this time. If the client is unable to void, a straight catheterization to empty the bladder is indicated, after which fundal height would then be reassessed. The nurse would not notify the client's midwife about the data unless the assessment remains unchanged after the client voids. Asking another nurse to verify the assessment findings is not an appropriate action.
503
Upon delivery of the newborn, which nursing intervention promotes parental attachment?
A) Placing the newborn under the radiant warmer
B) Placing the newborn on the bed next to the mother
C) Placing the newborn on the maternal chest
D) Taking the newborn to the nursery for the initial assessment
Answer: C
Explanation: A) Placing the baby on the maternal chest promotes attachment and bonding and gives the mother a chance to interact immediately with her baby. Removing the baby to the radiant warmer, allowing the mother a chance to rest immediately after delivery, and taking the newborn to the nursery for the initial assessment do not promote attachment.
504
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If a woman had a prepregnancy daily requirement of 1800 calories and she decides to breastfeed her newborn, how many calories should the nurse recommend the woman take in each day?
A) 2300 calories
B) 2500 calories
C) 2000 calories
D) 1800 calories
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Answer: A
Explanation: A) The breastfeeding mother should take in 500 more calories than her prepregnancy requirements. Therefore, she should take in 2300 calories each day. The woman who is not breastfeeding should return to her prepregnancy requirement of 1800 calories per day.
505
Answer: A
Explanation: A) The breastfeeding mother should take in 500 more calories than her prepregnancy requirements. Therefore, she should take in 2300 calories each day. The woman who is not breastfeeding should return to her prepregnancy requirement of 1800 calories per day.
Answer: B
Explanation: A) In the formal stage of maternal role attainment, the woman is influenced by the guidance of others and tries to act as she believes others expect her to act. The anticipatory stage occurs during pregnancy. The informal stage occurs when the mother begins to make her own choices about mothering. The personal stage occurs when the mother is comfortable with the notion of herself as "mother."
506
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Which symptom would the nurse recognize as being consistent with postpartum endometritis at 4 weeks postpartum?
A) Foul-smelling lochia
B) Bright red lochia
C) Upper abdominal pain
D) Bradycardia
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Which symptom would the nurse recognize as being consistent with postpartum endometritis at 4 weeks postpartum?
A) Foul-smelling lochia
B) Bright red lochia
C) Upper abdominal pain
D) Bradycardia
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507
A 16-year-old has just given birth, and she plans to keep and care for the baby. However, the nurse determines that the young mother has low self-esteem, and she does not appear to have adequate social support. The nurse should encourage adequate follow-up care for this young mother for what reason?
A) She is at risk for postpartum hemorrhage.
B) She is at risk for postpartum endometritis.
C) She is at risk for postpartum depression.
D) She is at risk for postpartum weight gain.
Answer: C
Explanation: A) Young mothers with low self-esteem, family conflict, and few social supports are more likely to encounter postpartum depression. The nurse should carefully assess the young mother for risk factors and provide appropriate referrals for follow-up. Having low self-esteem and no social support does not increase the adolescent's risk for postpartum hemorrhage. There is not enough information to determine if she is at risk for postpartum endometritis. She may be at higher risk for inadequate nutrition rather than excessive weight gain.
508
The nurse is providing discharge instructions for a healthy 37-year-old first-time mother and her newborn. What should the nurse include in her instructions for this mother and her spouse?
A) Information related to contraception and sexually transmitted infections (STIs).
B) A reminder that addition of a newborn will alter established routines.
C) A referral to a group class that provides information on newborn care.
D) A referral for follow-up care with healthcare providers other than the obstetrician.
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Answer: B
Explanation: A) Women who are over 35 have life experiences and education that often better prepare them for parenthood. However, older couples must be made aware that the addition of a newborn will alter established routines and practices. A referral for follow-up care with other healthcare providers is appropriate for women over 35 who have preexisting conditions or complications. Information related to contraception and STIs and referral to a group class on newborn care are more appropriate for adolescent mothers.
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509
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Answer: B
Explanation: A) Women who are over 35 have life experiences and education that often better prepare them for parenthood. However, older couples must be made aware that the addition of a newborn will alter established routines and practices. A referral for follow-up care with other healthcare providers is appropriate for women over 35 who have preexisting conditions or complications. Information related to contraception and STIs and referral to a group class on newborn care are more appropriate for adolescent mothers.
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Answer: A, B
Explanation: A) Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
510
The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first?
A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute.
B) Term newborn, 2 hours old, who has not passed a meconium stool.
C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations.
Answer: D
Explanation: A) Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is 30-60 breaths per minute. A normal pulse is 110-160 beats per minute. If a meconium stool is not passed within the first 24 hours, this would be cause for concern.
511
A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding?
A) Colostrum is bad for the baby.
B) The birthing process spoils breast milk.
C) It will cause "evil eye."
D) Newborns require feeding on demand
Answer: A
Explanation: A) Some Asian, Haitian, Hispanic, Eastern European, and Native American cultures believe breastfeeding should be delayed because colostrum is bad for the baby. A Haitian client may believe that strong emotions, not the birthing process, spoil breast milk. Some Latin American cultures do not believe that breastfeeding causes evil eye but rather that touching the head or the face of the baby when admiring it will ward off the "evil eye." Many Cambodian refugees practice breastfeeding on demand or provide a comfort bottle between feedings.
512
The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn?
A) Risk for Injury
B) Risk for Infection
C) Risk for Imbalanced Nutrition
D) Risk for Ineffective Breathing Pattern
Answer: B
Answer: B
Explanation: A) The client is at increased risk for infection because of the circumcision. Risk for Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating signs of ineffective feeding behaviors
513
A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply.
A) Assess blood glucose frequently.
B) Assess for SGA.
C) Assess for hyperthyroidism.
D) Assess the newborn's temperature hourly.
E) Assess for hyperbilirubinemia.
Answer: A, E
Explanation: A) In a newborn of a mother with diabetes, the onset of hypoglycemia occurs at 1-3 hours after birth and can continue for several days. Blood glucose levels should be checked frequently during the first several days. The nurse should assess lab results for hypocalcemia, hyperbilirubinemia, and polycythemia. Alterations in temperature and thyroid hormone levels are not associated with newborns of mothers with diabetes. Newborns of mothers with diabetes are often LGA (large for gestational age), not SGA (small for gestational age).
514
The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply.
A) "I should not use petroleum jelly on the penis."
B) "Every time I change the diaper I am to wash the area with warm water."
C) "I should report any pus drainage or change in diaper wetness to the physician."
D) "Swelling is expected."
E) "I am to use soap and water to remove yellow tissue on the penis."
Explanation: A) The nurse should instruct the mother to wash the area with warm water after every diaper change, to use petroleum jelly to protect the penis and prevent bleeding, and to report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is granulation tissue, which is evidence of healing and should not be washed off with soap and water. Swelling is not expected after a circumcision and should be reported to the physician.
515
When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply.
A) Using a 23-gauge 1/2-inch needle
B) Cleaning the skin with an alcohol swab
C) Preparing 5 mg of the medication for injection
D) Using the middle third of the vastus lateralis muscle
E) Washing the skin with soap and water
Answer: B, D
Explanation: A) A single dose of vitamin K (phytonadione) is administered to newborns within 1 hour of birth. The nurse should use the middle third of the vastus lateralis muscle, clean the skin with an alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.
516
The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session?
A) "Your baby's stools will change to a dark green color when your milk comes in."
B) "Your baby may spit up frequently for the first few weeks."
C) "Compress the bulb syringe before placing it in your baby's nose or mouth."
D) "You can wipe away any green drainage that might form around the umbilical cord."
Answer: C
Explanation: A) A bulb syringe is often used to suction excess secretions from the baby's nose and mouth. The bulb syringe should be compressed before placing it gently in the baby's nose or mouth. Stool color is often seedy and yellow or golden brown in color when breastfeeding. The baby may spit up frequently in the first day or two, but this should not continue for several weeks. Green drainage from the umbilical cord is abnormal and should be reported to the baby's provider.
517
The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding?
A) Respiratory rate of 58 breaths per minute
B) Heart rate of 140 beats per minute
C) Presence of meconium stool
D) Yellowing of the skin
Answer: D
Explanation: A) Yellowing of the skin within the first 24 hours of life is caused by pathologic jaundice and often requires treatment with phototherapy. All of the other assessment findings are considered normal during the first 24 hours of life.
518
The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate?
A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery
B) Swaddling the newborn to decrease the risk of increased energy expenditure
C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing
D) Repeating the assessment every 5 minutes for up to 20 minutes
Answer: D
Explanation: A) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.
519
The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings?
A) Preterm appropriate for gestational age
B) Term appropriate for gestational age
C) Preterm small for gestational age
D) Term small for gestational age
Answer: D
Explanation: A) The infant is term at 37 2/7 weeks. Because the weight is below the 10th percentile, the infant is not appropriate for gestational age but is considered small for gestational age.
520
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The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn?
A) Audiology specialist
B) Cardiac surgeon
C) Lactation consultant
D) Pediatrician
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Answer: B
Explanation: A) The healthcare team works together to care for the newborn. The team commonly includes a pediatrician or neonatal specialist, a nurse, a lactation consultant, and an audiology specialist. A cardiac surgeon will only be involved in the newborn's care if the newborn is diagnosed with a congenital cardiac disorder or birth defect.
521
) After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU), a client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment?
A) Limit visits to the intensive care unit so as not to disrupt care the baby needs.
B) Explain that once the baby is discharged to home, she will have evidence that the baby is real.
C) Have the mother visit when the baby is asleep or resting.
D) Provide a picture of the infant including a footprint and current weight and length.
Answer: D
Explanation: A) Nurses need to take measures to promote positive parental feelings toward the preterm infant. One way to do this would be to provide the mother with a picture of the infant, including a footprint and current weight and length. This promotes bonding. The mother needs to begin bonding with the infant now, not wait until the baby is discharged to home. Visits to the intensive care unit should be encouraged and supported. The mother should try to visit with the infant when the baby is awake to encourage interaction
522
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The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is appropriate based on this data?
A) Parental Role Conflict
B) Impaired Parenting
C) Dysfunctional Family Processes
D) Compromised Family Coping
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Answer: D
Explanation: A) Compromised Family Coping is the nursing diagnosis most appropriate for this situation at this time because the mother is expressing anger and guilt at having given birth to a premature baby. Parental Role Conflict is seen if the role of parent is in conflict with other expectations. Impaired Parenting is seen if the mother is unable to fulfill the role of mother to the baby. Dysfunctional Family Processes is seen if the addition of a baby leads to the family's inability to function as a family.
523
When planning the care for a preterm infant with ineffective thermoregulation, the nurse should include which intervention?
A) Keep the baby's head uncovered.
B) Rinse hands with cold water before providing care to the infant.
C) Place incubator near a window or source of fresh air.
D) Allow skin-to-skin contact with the mother to maintain warmth.
Answer: D
Explanation: A) The nurse needs to plan for a neutral thermal environment to minimize oxygen consumption, prevent cold stress, and facilitate growth of the preterm infant. To do this, the nurse should plan for the infant to have skin-to-skin contact with the mother to maintain warmth. The hands should be rinsed with warm water before providing care to the infant. The baby's head should be covered because the head is 25% of the baby's size and is prone to evaporative heat loss. Incubators should be moved away from drafts or open windows to reduce radiative and conductive heat loss
524
The nurse is instructing the parents who delivered their first child at 34 weeks' gestation. Which statements made by the parents indicate that additional teaching is needed? Select all that apply.
A) "Tube feedings will be required because his stomach is small."
B) "Breathing might be harder for our baby because he is early."
C) "Our baby will be in an incubator to keep him warm."
D) "The growth of our baby will be slower than if he were term."
E) "Because he came early, he will not produce urine for 2 days."
Answer: A, E
Explanation: A) Preterm infants grow more slowly than do term infants. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine. Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An incubator or radiant warmer is used to keep the baby warm. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants.
525
The nurse is monitoring the intake and output for a preterm infant. Which action by the nurse indicates correct assessment technique when monitoring urine output?
A) Document "unable to obtain" on the graphic sheet.
B) Apply an external condom catheter.
C) Insert an indwelling urinary catheter.
D) Weigh diapers using the estimate that 1 mL = 1 gram of weight.
Answer: D
Explanation: A) Weight change is one of the most sensitive indicators of fluid balance. Weighing diapers is the intervention used to accurately measure the output of an infant. The estimate is that 1 g of diaper weight is equal to 1 mL of fluid. The nurse should not insert an indwelling urinary catheter or apply an external condom catheter on the infant. Documenting "unable to obtain" on the graphic sheet does not support the need to accurately measure the infant's output.
526
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The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding?
A) Weigh the current diaper.
B) Measure abdominal girth.
C) Weigh the baby.
D) Measure pulse oximetry.
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Answer: B
Explanation: A) Before each feeding, the nurse should measure the abdominal girth to determine abdominal distention, which is seen in necrotizing enterocolitis or paralytic ileus. Weighing the baby and weighing diapers are interventions to assess for fluid volume status. Measuring pulse oximetry is an intervention for assessing oxygenation.
527
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A nurse is caring for a premature infant with a central line. The otherwise healthy, growing infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status?
A) Hyperbilirubinemia
B) Bacterial sepsis
C) Hypoglycemia
D) Intracranial hemorrhage
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Answer: B
Explanation: A) The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a central line in place who had previously been growing and doing well is suggestive of bacterial sepsis rather than hyperbilirubinemia, hypoglycemia, or intracranial hemorrhage.
528
The nurse is assessing a premature newborn who is being cared for in the newborn intensive care unit (NICU). Which assessment finding indicates the newborn is experiencing respiratory distress?
A) Acrocyanosis
B) Respiratory rate of 58 breaths per minute
C) Substernal and intercostal retractions
D) Abdominal breathing
Answer: C
Explanation: A) A premature newborn who is experiencing retraction may indicate respiratory distress. Acrocyanosis, a respiratory rate of 58 breaths per minute, and abdominal breathing are considered normal assessment findings in the premature newborn
529
Which factor contributes to increased respiratory complications in the preterm infant?
A) Increased constriction of blood vessels
B) Decreased prostaglandin E levels
C) Absence of muscular coat on pulmonary blood vessels
D) Inadequate surfactant
Answer: D
Explanation: A) The preterm neonate is unable to produce adequate amounts of surfactant in the lungs, decreasing compliance and increasing the pressure needed to expand the lungs with air. Collapsed alveoli do not facilitate exchange of oxygen and carbon dioxide, leading to hypoxia, inefficient pulmonary blood flow, and energy depletion. In preterm infants, the muscular coat on pulmonary blood vessels is incompletely developed, not absent, leading to decreased constriction of blood vessels. Prostaglandin E levels are increased, not decreased
530
Answer: D
Explanation: A) The preterm neonate is unable to produce adequate amounts of surfactant in the lungs, decreasing compliance and increasing the pressure needed to expand the lungs with air. Collapsed alveoli do not facilitate exchange of oxygen and carbon dioxide, leading to hypoxia, inefficient pulmonary blood flow, and energy depletion. In preterm infants, the muscular coat on pulmonary blood vessels is incompletely developed, not absent, leading to decreased constriction of blood vessels. Prostaglandin E levels are increased, not decreased
Answer: A
Explanation: A) The buffering capacity of the kidney is reduced in a preterm infant, predisposing the neonate to metabolic acidosis. Bicarbonate is excreted at a lower serum level, and acid is excreted more slowly. Therefore, the neonate is at higher risk for metabolic acidosis than metabolic alkalosis. Respiratory acidosis or alkalosis would be due to changes in lung physiology, not kidney physiology.
531
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A premature newborn's neuronal immaturity may contribute to what complication?
A) Apnea of prematurity
B) Patent ductus arteriosus
C) Respiratory distress syndrome
D) Anemia of prematurity
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Answer: A
Explanation: A) Apnea of prematurity is primarily a result of neuronal immaturity, causing irregular breathing patterns and cessation of breathing for 20 seconds or longer in preterm infants. PDA, respiratory distress syndrome, and anemia of prematurity have other etiologies related to the premature development of the neonate.
532
A young client is brought into the emergency department by a friend who says the client was "beat up" at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this client?
A) The client does not want the individual who did the beating to get in trouble.
B) The client does not know his parents.
C) The client does not want the school to get in trouble.
D) The client is a victim of interpersonal violence.
Answer: D
Explanation: A) The client's reluctance to provide parents' names or address could suggest the client is a victim of child abuse from parents rather than a victim of bullying at school. Either way, the client is clearly a victim of interpersonal violence. It is unlikely that the client does not know his parents. It is also unlikely that the client does not want to get the school or the individual who did the beating in trouble.
533
```
A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this data?
A) A protective factor
B) A risk factor
C) A vulnerability factor
D) A precipitating factor
```
Answer: C
Explanation: A) Vulnerability factors increase one's risk of being a victim of violence. The client with a walking disability avoids the possibility of a crime by not going out alone at night. A protective factor decreases the risk of perpetration and victimization. Risk factors increase the potential that one will perpetrate violence on others. Precipitating factors are those that give rise to a specific incident of violence.
534
A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply.
A) Explore options for self-development.
B) Improve quality of life by increasing self-esteem.
C) Explore options for help.
D) Convey safety.
E) Determine immediacy of danger.
Answer: C, D, E
Explanation: A) Short-term interventions for abuse include determining the immediacy of danger, conveying that the client has the right to be safe, and exploring options for help. Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults.
535
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After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next?
A) Conducting a team assessment
B) Medicating for anxiety as prescribed
C) Notifying the police
D) Treating the injuries
```
Answer: A
Explanation: A) If the nursing assessment reveals possible domestic violence, a primary focus will be treating the injuries. However, treatment is often done by a team, which means a team assessment needs to be conducted before treatment can take place. The police may need to be notified later. The degree of anxiety will determine whether the client needs medication.
536
The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is present?
A) Call the police to have the spouse arrested for assault.
B) Refuse to permit the spouse to visit with the client.
C) Call security to have the spouse removed.
D) Ask the client if there is anything that is needed at this time
Answer: D
Explanation: A) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and their family members. The nurse should ask the client if there is anything that is needed at this time. The nurse should not refuse to let the spouse visit unless it is the client's wish to do so. The nurse should not contact security or the police unless requested by the spouse.
537
) The nurse is providing care to a child who has suffered abuse. Which nursing actions are appropriate? Select all that apply.
A) Ask the child what he did to cause his parents to beat him so badly.
B) Tell the child that the individual who hurt them is a bad person.
C) Follow protocols for mandatory reporting.
D) Remind the child that he did nothing wrong.
E) Ask the child what really happened.
Answer: C, D
Explanation: A) The priority nursing consideration regarding the abused child is to ensure the immediate safety of the child. Beyond that, the abused child needs to be encouraged to talk about the abuse but must also be protected from having to provide multiple reports. The nurse working with the abused child needs to say that he or she believes the child's story; the nurse also must reassure the child that he or she has done nothing wrong. The nurse should avoid making negative comments about the abuser and must follow established protocols for mandatory reporting, documentation, and use of available support services.
538
```
The nurse is discharging a client who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse. The client states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw, we went to Rome." Based on this data, which phase of violence is the client experiencing?
A) The tension phase
B) The abusive phase
C) The honeymoon phase
D) The reconciliation phase
```
Answer: C
Explanation: A) The tension phase of the cycle of violence occurs when communication fails and tension builds. The abusive phase occurs when there is a violent incident. The honeymoon phase occurs when the aggressor shows love and affection. The cycle of violence will continue unless intervention occurs, and there is no reason for the client to expect it will stop or anticipate reconciliation and healing.
539
```
) The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply.
A) Involvement in the community
B) Participation in family activities
C) Residing in an impoverished community
D) Academic failures at a young age
E) Success in school
```
Answer: A, B, E
Explanation: A) Involvement in the community, participation in family activities, and success in school are all examples of protective factors. Protective factors decrease the risk of violence perpetration and victimization. Residing in an impoverished community is a predisposing factor. Academic failure at a young age is a risk factor for becoming a perpetrator.
540
```
) The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply.
A) Involvement in the community
B) Participation in family activities
C) Residing in an impoverished community
D) Academic failures at a young age
E) Success in school
```
Answer: A, B, E
Explanation: A) Involvement in the community, participation in family activities, and success in school are all examples of protective factors. Protective factors decrease the risk of violence perpetration and victimization. Residing in an impoverished community is a predisposing factor. Academic failure at a young age is a risk factor for becoming a perpetrator.
541
A client is brought into the emergency department after being in a motor vehicle crash. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this client?
A) Breathing and ventilation
B) Circulation with hemorrhage control
C) Airway maintenance with cervical spine protection
D) Disability and neurologic assessment
Answer: C
Explanation: A) When caring for the trauma victim, the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern be airway maintenance with cervical spine protection.
542
```
What type of communication should the nurse employ when caring for a client who has suffered trauma?
A) Assertive communication
B) Therapeutic communication
C) Passive communication
D) Aggressive communication
```
Answer: B
Explanation: A) Nurses need to employ therapeutic communication to help clients work through the stress and fear of the traumatic event and ultimately accept that the situation they experienced cannot be reversed. Nurses should never use passive or aggressive communication techniques with clients. Assertive communication may be helpful in some circumstances, but it is not as important as therapeutic communication.
543
The nurse is caring for several clients in the emergency department. Which individual is a victim of community violence?
A) A 32-year-old woman who was beaten by her spouse
B) A 20-year-old man who was shot during a gang dispute
C) A 6-month-old girl who was abused by her mother
D) A 76-year-old man who was neglected at a care facility
Answer: B
Explanation: A) Gang violence is a type of community violence, so traumatic injuries sustained during a gang dispute would be categorized as community violence. The other examples are related to interpersonal violence.
544
```
12) An individual who has experienced which type of trauma is likely to be most resilient?
A) Intimate partner violence
B) Bullying
C) Rape
D) Natural disaster
```
Answer: D
Explanation: A) Generally, survivors of natural disasters show resilience, and the stress responses do not become chronic or debilitating. Bullying and intimate partner violence may be ongoing, persistent stressors that prevent resiliency. Rape is an extreme traumatic event that may take months to years to recover from.
545
A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply.
A) Confusion
B) Missing teeth
C) Apprehension when other children cry
D) Abrasions to the mouth, lips, and genitalia
E) Dehydration
Answer: B, C, D
Explanation: A) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia; missing teeth; and apprehension when other children cry. Dehydration and confusion are manifestations of elder abuse.
546
) The nurse is providing care for a 2-year-old client. When assessing the client's risk for abuse, which factors increase this client's risk? Select all that apply.
A) The child has bruises on the knees and shins.
B) The child's parents are married.
C) The child is less than 3 years old.
D) The child is deaf.
E) The child's parents are unemployed and receive medical assistance.
Answer: C, D, E
Explanation: A) Risk factors for child abuse include poverty, age less than 3 years, and child disability or condition that requires a great deal of care. Marriage of the parents and bruises on the knees and shins are not risk factors for abuse.
547
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A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate?
A) Powerlessness
B) Risk for Other-Directed Violence
C) Ineffective Health Maintenance
D) Chronic Low Self-Esteem
```
Answer: A
Explanation: A) Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.
548
) The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client?
A) Assist the client to devise a safety or escape plan.
B) Encourage the client to take charge of the situation.
C) Offer to contact outpatient services if the client promises not to return home after discharge.
D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A
Explanation: A) A client who has been victimized by a partner should have a safety plan. This has the highest priority as the client's life is in danger. The client has no control over the partner, and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging the client to take charge is too general a statement to be helpful; the client needs specific tools to develop a safety plan. It may not be safe and feasible for the client to leave the situation right away, and resources should not be withheld if a client is unable to promise not to return home.
549
A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective?
A) "Everyone knows what my problems are, and there is nothing I can do about it."
B) "I am functioning fine now but I know that when problems come up again, I will ask for help."
C) "My friends tell me that I have improved so this is a good time to stop."
D) "It is so draining to deal with the same painful issues all of the time."
Answer: B
Explanation: A) The client acknowledging that future problems will come up indicates that the client has gained insight into problems. The client's willingness to ask for help shows that the client is prepared to continue with counseling when new problems arise. Stating that the process is draining and painful suggests that little progress has been made and that the client is looking to avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of treatment on the statements of others places emphasis on others and not on self-evaluation.
550
```
) An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply.
A) Poor hygiene
B) Dehydration
C) Intracranial trauma
D) Fecal impaction
E) Dislocations
```
Answer: A, B, D, E
Explanation: A) The nurse suspecting elder abuse would assess for clinical manifestations associated with elder abuse. Some of those clinical manifestations are constant hunger or malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it is a clinical manifestation of child abuse.
551
The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate?
A) Contact adult protective services.
B) Call the healthcare provider immediately.
C) Assess the client's cultural traditions.
D) Contact the client's family.
Answer: C
Explanation: A) The most appropriate action for the nurse at this time is to assess the client's cultural traditions. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.
552
A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take?
A) Discuss what the nurse witnessed with the infant's mother.
B) Discuss what the nurse witnessed with the other nurses.
C) Report what the nurse witnessed and assessed to the authorities.
D) Call security to remove the father from the room.
Answer: C
Explanation: A) Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant's mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.
553
Answer: C
Explanation: A) Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant's mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.
Answer: C
Explanation: A) Common elements of abuse include humiliation, intimidation, and physical injury. Injury associated with abuse is not accidental. Feelings of control and use of manipulation tactics are related to the perpetrator, not the victim.
554
```
Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors?
A) Social learning theory
B) Psychopathology theory
C) Neurobiology theory
D) Environmental theory
```
Answer: A
Explanation: A) Social learning theory explains that individuals learn violent tendencies through association with others and a reinforcement of the abusive behavior. Psychopathology theory suggests that some individuals who experience personality disorders and mental illnesses participate in family violence as a result of these illnesses. Neurobiology theory asserts that genetics plays a role in anger modulation and emotion control. Environmental theory is not related to the etiology of abuse.
555
```
Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain?
A) Ultrasound
B) X-ray
C) MRI
D) Blood test
```
Answer: A
Explanation: A) An ultrasound or CT scan of the abdomen can check for abdominal or organ injuries. An MRI of the spine will show spinal injuries. X-rays can detect fractured bones. Blood tests may be used to detect sexually transmitted diseases.
556
```
An older adult man is transported to the emergency department after a motor vehicle crash. Which risk factors for the older adult could have contributed to the crash? Select all that apply.
A) Unsafe driving practices
B) Preexisting health conditions
C) Speeding
D) Texting
E) Reduced sensory perception
```
Answer: B, E
Explanation: A) Older adults are at risk of motor vehicle crashes due to preexisting health conditions and decreased sensory perceptions. Younger adults are at risk of motor vehicle crashes due to unsafe driving practices, speeding, and texting or other distractions.
557
The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. Which is an appropriate client goal for the nurse to include in the plan of care?
A) The client will have adequate urine output.
B) The client will regain mobility.
C) The client will participate in self-care activities.
D) The client will be discharged to home
Answer: B
Explanation: A) The client has sustained multiple lower extremity fractures. A goal of care for this client is for the client to regain mobility. An adequate urine output is important, but healing the client's fractures needs to be a goal of care. Participating in self-care activities and being discharged to home are also important; however, because the client sustained multiple fractures to the lower extremities, one goal of care must be focused on the client regaining mobility.
558
A client was admitted to the hospital after a crush injury to the chest. The client sustained multiple rib fractures, a collapsed lung, and several skin abrasions. After the client is stabilized, which nursing intervention would be a priority for this client?
A) Monitor urine output.
B) Assess vital signs.
C) Perform passive range of motion to all extremities.
D) Assist to deep breathe and cough every 2 hours
Answer: D
Explanation: A) The client has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the client breathes deeply and coughs every 2 hours to mobilize secretions and prevent respiratory complications. Monitoring urine output and assessing vital signs are important but not the priority at this time. The client may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated.
559
```
A client is admitted to the emergency department with an incomplete spinal cord injury after a fall from a roof. Which prescription does the nurse anticipate to decrease inflammation and nerve damage?
A) Hydrocodone (Vicodin)
B) Ibuprofen (Motrin)
C) Methylprednisolone (Medrol)
D) Xylocaine (Lidocaine)
```
Answer: C
Explanation: A) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease inflammation and prevent nerve damage. Hydrocodone (Vicodin) is a pain relief medication. Ibuprofen (Motrin) is an anti-inflammatory given to clients to reduce swelling, such as joint swelling. Xylocaine (Lidocaine) is injected into the affected muscle to relieve pain and muscle spasms, such as muscle spasms related to whiplash.
560
The nurse at a local hospital is conducting a safety workshop for expectant parents addressing newborn injury prevention and car seat safety. Which statement made by a parent indicates a need for further teaching?
A) "My newborn should be in a car safety seat every time he is in the car."
B) "My baby can ride facing forward as long as he is in a convertible car seat suitable for an infant."
C) "My newborn should ride in a rear-facing car seat."
D) "Never place a rear-facing car safety seat in the front seat with an active passenger air bag."
Answer: B
Explanation: A) Infants should always ride in a rear-facing car seat, even if it is a convertible seat suitable for an infant. Therefore, the statement relating to the infant facing forward is incorrect and indicates a need for further instruction. The other statements are correct and indicate no need for further education.
561
A nurse is developing a plan of care for a client with traumatic injuries after a natural disaster. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours
A nurse is developing a plan of care for a client with traumatic injuries after a natural disaster. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours
562
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What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.
A) Airway maintenance
B) Obtaining medical history
C) Ventilation assistance
D) Hemorrhage control
E) Hypothermia prevention
```
Answer: A, C, D, E
Explanation: A) Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the client's neurologic status, as well as prevention of infection. While obtaining the client's medical history is important, this action would not be priority and would take place after the priority assessment and treatment. Once the safety of the client is assured, then the nurse will manage the client's emotional state and obtain the medical history.
563
A client is brought into the emergency department after being assaulted. The provider suspects that the client has a spinal cord injury. Which diagnostic tests does the nurse anticipate based on the data collected? Select all that apply.
A) Computed tomography (CT) scan
B) X-ray
C) Ultrasound
D) Magnetic resonance imaging (MRI)
E) Positron emission tomography (PET) scan
Answer: A, D
Explanation: A) Both MRIs and CT scans can be used to assess spinal cord injuries, among other injuries. An x-ray will be performed for potential fractured bones. An ultrasound is performed if internal bleeding is suspected. A PET scan is used to look for disease within the main organs of the body.
564
```
Which cause of multisystem trauma is the leading cause of injury death in the United States?
A) Poisonings
B) Motor vehicle crashes
C) Assault
D) Natural disasters
```
Answer: A
Explanation: A) Poisonings are the leading cause of injury death in the United States, and all causes of fatal injuries are also causes of multisystem trauma. Motor vehicle crashes are also a major concern because of the significance of injuries sustained, but they are not the leading cause of injury death. Assault and natural disasters are not leading causes of injury death.
565
```
A client lost consciousness after being hit by a falling piece of equipment on a work site. What type of injury should the nurse assess this client for as the highest priority?
A) Fractured bones
B) Traumatic brain injury
C) Whiplash
D) Spinal cord injury
```
Answer: B
Explanation: A) Loss of consciousness is a sign of traumatic brain injury, and any injury to the brain should be assessed with highest priority. Fractured bones and spinal cord injury may also need to be assessed depending on the location of the injury and the client's other clinical manifestations, but these would be a lower priority than assessing for traumatic brain injury. Whiplash usually results from a motor vehicle crash, so assessing for whiplash would be low in priority.
566
If a pregnant woman sustains multisystem trauma, in which order should assessment occur?
A) Primary assessment of the mother, secondary assessment of the mother, primary assessment of the fetus
B) Primary assessment of the mother, primary assessment of the fetus, secondary assessment of the mother
C) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the mother
D) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the fetus
Answer: B
Explanation: A) If a pregnant woman sustains multisystem trauma, the best treatment for the fetus is resuscitation of the mother. Therefore, the mother should be assessed first, then the fetus. Once both have been assessed and stabilized, then the secondary assessment of the mother should be performed.
567
During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the client's behavior?
A) The client thought there was an earthquake.
B) The client was reacting to the loud noise as a form of a flashback.
C) The client wanted to check the cause of the loud noise.
D) The client thought the assessment was concluded
Answer: B
Explanation: A) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.
568
The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply.
A) Observed family member being raped and murdered
B) Restores antique automobiles as a hobby
C) Lives with spouse and has a garden
D) Has a history of anxiety disorder
E) Recently terminated from employment
Answer: A, D, E
Explanation: A) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder
569
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A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply.
A) Difficulty sleeping
B) Hypovigilance
C) Alcohol abuse
D) Aggressive behavior
E) Hair pulling
```
Answer: A, C, D
Explanation: A) Aggressive behavior, alcohol abuse, and difficulty sleeping are clinical manifestations of posttraumatic stress disorder. Hypervigilance, not hypovigilance, is associated with PTSD. Hair pulling is not a symptom of PTSD.
570
```
A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is the priority for this client?
A) Fear
B) Anxiety
C) Post-Trauma Syndrome
D) Ineffective Coping
```
Answer: C
Explanation: A) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
571
The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago. Which should the nurse include in the client's plan of care?
A) Guidelines on conducting activities of daily living
B) Information on the treatments available
C) Referral to local employment agency
D) Information on the need for adequate exercise
Answer: B
Explanation: A) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
572
The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply.
A) The client takes a sedative at least four times a day.
B) The client has been sleeping throughout the night.
C) The client keeps all of the lights on at home.
D) The client verbalizes future plans with family and friends.
E) The client will not enter a car with fewer than three people.
Answer: B, D
Explanation: A) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives four times a day is exhibiting behavior that indicates interventions have not been successful.
573
Which nursing interventions would be appropriate for a client demonstrating extreme anxiety related to posttraumatic stress disorder (PTSD)? Select all that apply.
A) Encourage the client to discuss what caused the syndrome to develop.
B) Provide a calm, quiet environment.
C) Give the client paperwork to complete while waiting to be assessed.
D) Ask the client what is causing the anxiety.
E) Reassure the client that the environment is safe.
Answer: B, E
Explanation: A) The client diagnosed with PTSD who is exhibiting extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of his or her safety. The client should not be given paperwork to complete. Asking the client what is causing the anxiety and encouraging the client to discuss what caused the syndrome to develop are not effective interventions for acute anxiety related to this disorder and should not be done.
574
```
A client is admitted with a diagnosis of posttraumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, which medication prescription does the nurse anticipate for this client?
A) Propranolol (Inderal)
B) Prazosin (Minipress)
C) Risperidone (Risperdal)
D) Fluvoxamine (Luvox)
```
Answer: B
Explanation: A) Prazosin is an antihypertensive medication that may be prescribed for treatment and prevention of nightmares. Propranolol (Inderal) is a beta-blocker; its possible uses include management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an antipsychotic that may be used in the treatment of obsessive-compulsive disorder (OCD) or panic disorders. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of OCD.
575
A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the client's plan of care?
A) The client will report a reduction in or cessation of nightmares.
B) The client will report a decreased perception of anxiety.
C) The client will discuss emotions related to traumatic experiences.
D) The client will remain free from injury or harm.
Answer: D
Explanation: A) Ensuring that the client remains free of injury would be the priority goal. The client was admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety is a priority. The other goals are relevant to the care of the client; however, they are not the priority goals.
576
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A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD) who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client?
A) Disturbed Sleep Pattern
B) Post-Trauma Syndrome
C) Risk for Other-Directed Violence
D) Risk for Self-Directed Violence
```
Answer: D
Explanation: A) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
577
```
Which individual has the highest risk of developing PTSD?
A) Victim of assault
B) Natural disaster survivor
C) Motor vehicle crash survivor
D) Military veteran
```
Answer: D
Explanation: A) Although all of these individuals may develop PTSD, the incidence of PTSD is particularly high among military personnel who have been deployed in overseas combat.
578
```
Which form of therapy might be used to help an individual with posttraumatic stress disorder (PTSD) visit the location where a traumatic event occurred?
A) Cognitive-behavioral therapy
B) Dual attention stimulus therapy
C) EMDR therapy
D) Exposure therapy
```
Answer: D
Explanation: A) Exposure therapy assists the patient by gradually exposing them to elements of the traumatic event using writing, pictures, and visiting the place where the traumatic event occurred. Cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and dual attention stimulus are all forms of therapy that might be used to help treat an individual with PTSD, but these types of therapy do not involve visiting the location where the traumatic event occurred.
579
The nurse is assessing a 4-year-old child. Which assessment finding indicates to the nurse that the child might have suffered a traumatic event?
A) The child refuses to talk or answer questions when previously the child chatted constantly.
B) The child draws pictures of family when previously the child drew pictures of animals.
C) The child complains of a stomachache and has a fever.
D) The child plays quietly in a corner when previously the child sat on his mother's lap.
Answer: A
Explanation: A) Forgetting how to talk or not talking at all are signs of posttraumatic stress disorder (PTSD) in children under the age of 6. A child with PTSD may draw pictures that symbolize the trauma, not simple pictures of family or animals. Somatic complaints are more common in older adults with PTSD and likely indicate conditions other than PTSD in young children. Children with PTSD may behave recklessly or aggressively, not play quietly.
580
The nurse is assessing two clients: a 23-year-old man who recently returned from overseas deployment with the military and a 68-year-old man who served in the military during the Vietnam War. Both clients have been diagnosed with posttraumatic stress disorder (PTSD). Which statement did the nurse likely record from the 68-year-old man?
A) "I startle at every sudden noise I hear, whether it is loud or quiet."
B) "I haven't had much of an appetite lately, and I keep forgetting important things."
C) "I just want to go out and hit someone."
D) "I feel so guilty that I came home and three of my good buddies didn't."
Answer: B
Explanation: A) Older veterans may report more somatic complaints, such as loss of appetite, sleep disturbances, and cognitive problems, than younger veterans with PTSD. Older veterans are also less likely to have typical PTSD symptoms such as an exaggerated startle response and exhibit less depression, hostility, and guilt than younger veterans with PTSD.
581
The nurse is caring for a victim of rape. Which interventions should the nurse include in the client's plan of care? Select all that apply.
A) Notifying an attorney for the client
B) Supporting the victim during the examination
C) Identifying the individual who committed the rape
D) Treating acute injuries
E) Providing referrals for follow-up care
Answer: B, D, E
Explanation: A) Priorities of nursing care include treating any acute injuries, supporting the victim during the examination, and providing referrals for follow-up care. Nursing priorities do not include identifying the individual who committed the rape or notifying an attorney for the client.
582
```
A client, who was raped and refuses to see any male healthcare providers, tells the nurse that she had an "incident" that she does not want to talk about, and wants a bed by the door. Which nursing diagnosis is appropriate for the client?
A) Relocation Stress Syndrome
B) Readiness for Enhanced Power
C) Rape-Trauma Syndrome
D) Acute Confusion
```
Answer: C
Explanation: A) Rape-Trauma Syndrome can manifest itself in many ways depending on the client. Some clients, such as this one, exhibit fear, especially of individuals of the same gender as the attacker. Clients may also exhibit humiliation, shame, and distrust in others. This client is not displaying evidence of readiness for enhanced power. There is no evidence that the client is experiencing relocation stress syndrome or acute confusion.
583
The nurse is providing care for a client who was the victim of sexual abuse 8 months ago. Which ongoing, long-term treatment goals are appropriate? Select all that apply.
A) The client's symptoms of anxiety and fear will decrease.
B) The client will involve significant others in the treatment plan.
C) The client will be able to verbalize legal rights.
D) The client will establish rapport and build a trusting nurse—client relationship.
E) The client will learn how to reconnect with others.
Answer: A, E
Explanation: A) Decreasing symptoms of anxiety and fear and learning how to reconnect with others may take months or years, whereas the other treatment goals can be met in the short term (hours to days). The nurse should have involved significant others in the treatment plan, established rapport, and made the client aware of legal rights immediately after the sexual abuse occurred.
584
```
A client recovering from a rape tells the nurse that flashbacks do occur but can be managed. Which techniques should the nurse suggest to the client for managing flashbacks about the event? Select all that apply.
A) Restoring personal choice
B) Deep breathing
C) Muscle relaxation
D) Problem solving
E) Guided imagery
```
Answer: B, C, E
Explanation: A) Techniques that the client can use to control flashbacks include muscle relaxation, deep breathing, and guided imagery. Problem solving and restoring personal choice are techniques to support coping behaviors.
585
A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate?
A) "The baby could always be given up for adoption."
B) "You will not know for sure for at least a few more days."
C) "Emergency contraception is available to prevent pregnancy."
D) "Are you sure the rapist did not use a condom?"
Answer: C
Explanation: A) Female rape victims may request information about emergency contraception if the attacker did not use a condom. The nurse should not tell the client that it will be a few more days to know for sure if she is pregnant. The nurse should not question whether the rapist used a condom. The client does not want to get pregnant. The nurse should not talk about giving a baby up for adoption at this time.
586
```
The nurse working in the emergency department is aware that rape victims initially exhibit which emotions? Select all that apply.
A) Shock
B) Disbelief
C) Anger
D) Self-blame
E) Humiliation
```
Answer: A, B
Explanation: A) Initial responses to rape generally include feelings of shock and disbelief. Anger, humiliation, and self-blame are early responses but not typically the initial response.
587
```
A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted syphilis. Which prescription does the nurse anticipate for this client?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Tinidazole
D) Doxycycline
```
Answer: A
Explanation: A) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and either azithromycin or doxycycline. Trichomoniasis is treated with tinidazole or metronidazole. Chlamydia is treated with doxycycline.
588
```
A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted trichomoniasis. Which prescription does the nurse anticipate for this client?
A) Penicillin
B) Ceftriaxone and azithromycin
C) Metronidazole
D) Doxycycline
```
Answer: C
Explanation: A) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and azithromycin. Chlamydia is treated with doxycycline.
589
```
Which type of rape often involves the use of date rape drugs?
A) Acquaintance rape
B) Marital rape
C) Anal rape
D) Gang rape
```
Answer: A
Explanation: A) The most common type of rape that uses date rape drugs is acquaintance rape, which is rape committed by an acquaintance or other familiar individual. Although the other types of rape may involve date rape drugs, this is far less common than for acquaintance rape.
590
```
The nurse is caring for a client who has a history of being physically and sexually abused as a child, and his father abandoned the family when he was 7 years old. The nurse recognizes that this increases the client's risk of becoming a perpetrator of rape because of which type of risk factors?
A) Individual
B) Relationship
C) Community
D) Societal
```
Answer: B
Explanation: A) Relationship risk factors for perpetration include a family environment characterized by physical violence and conflict; a childhood history of physical, sexual, or emotional abuse; and poor parent-child relationships, particularly with fathers. Although the client may also have individual, community, or societal risk factors as well, the factors the nurse has identified here are relationship risk factors.
591
A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client's plan of care before discharge?
A) Help the client find a new long-term care facility.
B) Help the client create a post-discharge safety plan.
C) Help the client find a lawyer to sue the long-term care facility.
D) Help the client understand the warning signs of suicide
Answer: B
Explanation: A) Younger and older individuals who are living with a caregiver may need help creating a post-discharge safety plan after a rape, especially if the perpetrator was the caregiver. This would be an important intervention to include in this client's plan of care. The nurse is not responsible for helping the client find a lawyer or a new long-term care facility, although the nurse may refer the client to someone who can help in these areas. The nurse should watch for warning signs of suicide and teach warning signs to family members, but helping the client understand warning signs of suicide could cause the client to avoid the warning signs if suicidal, which could cause harm to the client.
592
The nurse is preparing to teach a class about date rape to a group of college-age students. When discussing date rape drugs, which method of prevention should the nurse include in her presentation?
A) Never leave a location with a friend.
B) Only accept premade drinks from someone you know.
C) Never leave your drink unattended.
D) Only consume drinks handed to you directly by the bartender or a waitress.
Answer: C
Explanation: A) The nurse should include several methods of prevention in her presentation, including the instruction to never leave your drink unattended. Individuals are often given date rape drugs by acquaintances, so accepting premade drinks even from an acquaintance may not be safe. Individuals should watch their drink being made by the bartender rather than trusting that all drinks coming directly from a bartender or waitress are safe. Individuals may leave a location with a friend that they explicitly trust even if they feel they have been drugged.
593
Sensory perception
The process of receiving external stimuli or data.
594
What are external stimuli?
Visual, auditory, olfactory, tactile and gustatory
595
What are internal stimulis?
gustatory, kinesthetic and visceral
596
What is the ability to perceive movement and sense of position?
Kinesthesia
597
What is stereognosis?
The ability to perceive and understand an object through touch
598
Viscera
of or relating to any large organ in the body ex. when a stomach is full
599
stimulus
this is an agent or act that stimulates nerve receptor
600
Receptor
a nerve cell acts as a receptor by converting the stimulus to a nerve impulse. most are sensitive to only one stimulus, such as visual auditory or touch
601
impulse conduction
the impulse travels along the nerve pathway to the spinal cord or directly to the brain.
602
Perception
awareness and interpretation of stimuli takes place in the brain.
603
Olfactory 1
sense of smell
604
optic 3 Oculomotor
eyeball movement-eyelid
constriction of pupil
propriocetion
up down
605
optic 2
vision
606
Trochlear 4
later eyeball movement
607
trigeminal 5
sensation of scalp, upper eyelid, nose, nasal cavity, cornea, lacrimal gland, palate, upper teeth, cheek, top lip, chin, lower teeth, temporal scalp chewing
608
abducens 6
lateral eyemovement
609
facial 7
facial muscles, lacrimal secretions, nasal, submandibular sublingual glands, sensation of taste
610
Accoustic vestibulocochlear 8
balance and hearing
611
Glossopharyngeal
swallowing, gag, salivation, taste, touch pressure and pain from pharynx and posterior tongue, carotid arteries, regulates blood pressure
612
vagus 10
swallowing cardiac rate, respiration, digestion, sensation from stomach and thoracic spine, taste, proprioception
613
accessory 11
movement of head and neck, proprioception
614
hypoglossal
movement of tongue for speech and swallowing
615
cognition
process by which an individual learns, store, retrieves, and uses information
616
awareness
is the ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and actions
617
common causes of vertigo
strokes, brain tumors, head trauma, virus, idiopathic with no cause, most common is vestibular neruitis
618
BPPV-benign paroxysmal positional vertigo
caused by disruption of the orientation of ear otoliths. 42% of vertigo cases
619
color blindness
```
1-10 men-very few women. one or more missing pigments within the cones in the retina.
usually:
red and green
blue and yellow
rare-any color
```
620
achromatopsia
cannot distinguish any color
621
impaired sense of smell
```
most common: due to respiratory illness
normal aging
medications: cholesterol lowering or antibiotics
smoking
radiation treatment for head and neck
more rare: brain tumor, ms, parkinsons
```
622
taste disturbances
```
normal part of aging
medication
smoking
infection
gum disease
```
623
myopia
near sighted 23.9% at 40
624
hyperopia
far sighted 10% at 40 years
625
blindness
.9% 20/200 visual acuity
626
Cataracts
17.1%
627
diabetic retinopathy
5.4%
628
age related macular degeneration
2.1%
629
open angle glaucoma
1.9%
630
taste and smell disturbances are associated with age but not what?
Gender
631
Who are at high risk of sensory impairment when exposed to rubella, toxoplasmmosis or virus?
infants by their mothers
632
Common causes of blindness in infants?
retinopathy of prematurity, low birth weight and congenital cataracts
633
what is a major cause of prenatal visual and hearing disturbances
Fetal alcohol syndrome FAS
634
blindness, cataracts and glaucoma are most common in what culture?
African Americans
635
how often should an African American patient have an eye exam?
every 2 years unless they have diabetes then every year
636
glaucoma is most common in which cultures?
african american and hispanic
637
Cognition nursing implications
```
assess:
sensory function
patient history
physical exam
mental status
loss or decrease of one or more senses
provide reorientation as needed
involve other members of health care team if deficits are noted
```
638
refractive error occurs 2 to 3 times more often in?
American indian and alaskan natives
639
Communication nursing implications
for impaired vision:
provide verbal instrucitons
describe all parts of assessment especially touch
written instructions if required
provide instructions to family or caretakers
hearing impaired:
written instructions
engage sign language interpreter
provide translation of questions and answers
same for non english speaking
640
vision assessment includes:
```
assess:
farsighted -
nearsighted -myopia
presbyopia young
hyperopia older
cardinal field
nystagmus
assess strabismus
assess convergence
assess corneal reflex
assess pupil size/equality
anisocoria
assess direct pupil resp
assess consensual pupil resp-twice-
morphine
cholinergic (unresp)
assess accommodation
assess Ptosis
assess lacrimal
assess bulbar/palpebral conjunctiva
asses sclera
asses corneal-clarity
assess corneal-reflex
assess iris
palpate lacrimal, puncta nasolacrimal duct
```
641
Independent nursing interventions for sensory perception include:
preventing injury
restoring or maintaining function
promoting comfort
preventing sensory overload or deprivation
