Which contraceptive method is most appropriate for a woman whose history reveals two episodes of thrombophlebitis with her previous pregnancy, repeated Candida infections, and gestational diabetes and who wants to postpone pregnancy for at least 1 year? Oral contraceptive pill. Tubal ligation. Diaphragm. Intrauterine device. Of the family planning options presented, a diaphragm and jelly is the optimum choice for this woman. Answer 1 is incorrect because oral contraceptives are contraindicated with a history of thrombophlebitis. Answer 2 is incorrect because she is interested only in postponing pregnancy. Answer 4 is incorrect because use of intrauterine devices is contraindicated for women with impaired responses to infection, such as diabetics Select the option that is not a risk factor/contraindication with this woman's history. Which of the following identifies the basal body temperature (BBT) change characteristic of ovulation? Falls slightly, then increases by about 0.5°C. Rises slightly, then falls by about 0.5°C. Is affected by a surge of FSH. Is due to an estrogen surge. Basal body temperature falls slightly immediately before ovulation, then rises approximately 0.5°C. This characteristic finding aids women in identifying the fertile period of their cycle. Answer 2 is incorrect because the pattern described is reversed. Answers 3 and 4 are wrong because ovulation is related to an LH surge Remember the characteristic pattern: When calculating the 1-minute Apgar, the nurse adds the following assessment findings: heart rate—over 100; respiratory effort—slow and irregular; muscle tone—flaccid response to slap on soles of feet; weak cry; color—body pink, extremities blue. In view of these assessment findings, which Apgar score should the nurse record? 5 6 7 8 Heart rate—2; respiratory effort—1; muscle tone—0; reflex response—1; color—1. Total Apgar score is 5. Answers 2, 3, and 4 are incorrect because of inaccurate allocation of points for behaviors described Use the acronym APGAR to help remember the five areas for assessment: A—Appearance, P—Pulse, G—Grimace, A—Activity, R—Respiratory effort. A woman 36 weeks pregnant is admitted directly from clinic, with a blood pressure of 146/98, puffy face and hands, and "awful headaches and problems seeing." Admission note states: Admit stat for preeclampsia. Which nursing order should be questioned? Assess reflexes and amount and distribution of edema every shift. Up as desired. Admission and daily weight. Test urine for protein every 4 hours. If avoidable, women hospitalized for treatment of preeclampsia should be on bed rest in a quiet environment to minimize stimuli. Answer 1 is incorrect because the nurse should assess the amount and distribution of edema. Answer 3 is wrong because weight is an indicator of edema and diuresis and should be assessed in the preeclamptic woman. Answer 4 is wrong because I & O relationships and the presence and amount of protein in the urine arc important indicators of her status This question asks for the wrong answer; three of the options are appropriate orders. Select the one that is not Objectives for the initial prenatal visit include determining a woman's present health status, validating pregnancy, and identifying factors that may affect or be affected by a pregnancy. Which assessment finding indicates a need for further evaluation? Urinary frequency, nausea, fatigue. Vital signs—'1' 98.2, P 92, R 20, BP 110/70. Urine—negative for sugar, trace of protein. Marked vaginal discharge with itching for the past few days. Marked vaginal discharge with itching for the past few days indicates a need for further assessment. Itching is most commonly associated with vaginal infections, and the cause should be identified and treated. Altered vaginal pH in pregnancy contributes to increased susceptibility to infection. Answer 1 is incorrect because urinary frequency, nausea, and fatigue are common complaints in early pregnancy. Answer 2 is wrong because vital signs are within normal limits. Answer 3 is wrong because normally increased vaginal discharge in pregnancy may contaminate voided urine and result in a nonpathological trace of protein Reword the question when the stem asks for "a need for further evaluation." The best answer will have an incorrect statement. Health teaching about over-the-counter pregnancy test kits should include which of the following information? False-negative tests may be due to dilute urine secondary to diuresis and inaccurate technique. Urine tests are classed as presumptive signs of pregnancy. Levels of progesterone from the corpus luteum are sufficient to diagnose pregnancy as early as the fourth week. Urine tests are classed as positive signs of pregnancy. The most common cause of false-negative findings in urine testing for signs of pregnancy (presence of HCG) is faulty technique; further, dilute urine secondary to diuresis may contain too little hormone to register in the routine over-the-counter (or office) pregnancy tests. Note: HCG levels peak approximately 50-60 days after conception. Answer 2 is incorrect because urine tests are classed as "probable" signs of pregnancy. Answer 3 is incorrect because pregnancy tests identify presence/levels of HCG (the biological marker for pregnancy). Answer 4 is wrong because urine tests are classed as "probable" signs of pregnancy Eliminate the two options that state that urine tests are presumptive and positive signs of pregnancy. Eliminate the incorrect marker of pregnancy (3). A woman appears excited, euphoric, and eager to learn about her labor status. Her behavior supports the nursing assessment that she is progressing through which phase of labor? Latent. Active. Transitional. Prodromal. These behaviors are typical of a woman during the latent phase of labor. Answer 2 is incorrect because, as labor progresses, internal stimuli demand more focus. Answer 3 is wrong because women in transitional phase are irritable and increasingly aware of their labor as contractions increase in strength, length, and discomfort. Answer 4 is wrong because, in the prodromal period of labor, contractions are mild and irregular and her major question may be "Am I really in labor?" A memory device to match expected behavior with correct phase of labor: latent = lively (i.e., excited, eager to learn). Thirty minutes after the birth of twins, a new mother's fundus is "boggy" and her lochial flow increased. After massage to firm the fundus, and while supporting the uterus with a hand above the symphysis, the nurse expresses several large clots. Which action should the nurse take next? Notify the physician because the site of her bleeding must be located. Notify the physician because she needs surgery. Administer oxytocin according to prn order. Reapply perineal pad and tell her to keep her thighs together. The most common cause of bleeding immediately post partum is uterine atony, and bleeding may be controlled with fundal massage and oxytocic stimulation. Answer 1 is incorrect because the patient has responded to the nursing measures. Answer 2 is wrong because her bleeding does not appear to be associated with lacerations that might require surgery. Answer 4 is wrong because perineal pressure is effective only in treating superficial tears Key word is "next" action. Eliminate the two options about notifying the MD when the problem is under control. Choose the only option that has a prn medication. While performing a newborn assessment, the nurse notes yellowish vernix. The nurse promptly calls this to the physician's attention because this may be a sign of: Rh or ABO incompatibility or maternal ingestion of sulfisoxazole (Gantrisin). An intrauterine gonorrheal infection. Maternal diabetes mellitus. Fetal postmaturity. Yellow vernix results from the breakdown of hemoglobin or bile pigments in meconium. Both maternal anti-Rh-antigen antibodies and ingestion of sulfisoxazole (Gantrisin) are implicated in hemolysis of fetal RBCs. Answer 2 is incorrect because gonorrheal infection is opaque, thick, and odorous without discoloring vernix. Answer 3 is wrong because diabetes does not have any effect on the color of vernix. Answer 4 is wrong because the postmature fetus does not have vernix Eliminate the three options that have no effect on the vernix. Which plan should the nurse recommend to a pregnant woman for morning nausea? Eat a high-protein snack at bedtime. Eat two dry crackers or toast before arising. Eat a high-protein breakfast. Drink a glass of orange juice immediately on awakening. Carbohydrates taken before arising seem to reduce symptoms of morning nausea; dry crackers may absorb stomach acid and raise blood sugar. Answer 1 is incorrect because high-protein snacks at bedtime appear to have no effect on nausea in the morning. Answer 3 is wrong because nausea is present before eating and may be severe enough to prevent eating. Answer 4 is wrong because orange juice on an empty stomach may precipitate emesis in a woman with "morning sickness." Key point is time-frame: before getting out of bed. Choose dry over acidic fluid. Which of the following best explains indigestion, heartburn, and constipation during pregnancy? Progesterone, produced by the placenta, causes reduced motility of smooth muscle, e.g., intestinal tract. Stress due to developmental tasks of pregnancy results in increased gastric acidity and reflux. Pressure from the growing uterus displaces the stomach and intestines. Increased pancreatic activity results in digestive-tract fat intolerance. The effects of progesterone on the GI tract include relaxation of the cardiac sphincter and delayed gastric emptying, which contribute to indigestion and heartburn, and slowed intestinal peristalsis, which increases water reabsorption and predisposes to constipation. Answer 2 is incorrect because the major cause of symptoms is described in Answer 1. Answer 3 is wrong because displacement due to pressure from the uterus is secondary to the effects of reduced smooth muscle tone. Answer 4 is wrong because increased pancreatic activity does not cause fat intolerance Select the option that explains hormonal influences. When preparing the room for a woman with preeclampsia which equipment items are most important to have ready? Suction and oxygen apparatus. Urinary retention catheter and drainage bag. Electronic blood pressure monitor. Padded tongue blade and airway. is correct because the nurse's primary responsibility is to prepare for respiratory and cardiac support in case the woman experiences an eclamptic seizure. Answer 2 is incorrect because not all preeclamptic women require bladder catheterization. Answer 3 is incorrect because the nurse may monitor blood pressures using the standard sphygmomanometer and arm cuff. Answer 4 is incorrect because tongue blades are never used to manage seizures today Think airway first! A mother who just gave birth saturates her perineal pad in 15 minutes. Her fundus is firm and smooth, and there is a constant trickle of blood from the vagina. No clots can be expressed when the fundus is massaged. On the basis of these findings, what should the nurse suggest? Atonic bleeding. Traumatic bleeding. Retained placenta] fragments. Inverted uterus. Traumatic bleeding (e.g., birth canal or cervical lacerations) is characterized by a firm, smooth uterus and a continuous trickle. Answer 1 is incorrect because the uterus remains well contracted. Answer 3 is wrong because bleeding from retained placental fragments occurs most commonly later in the postpartum period. Answer 4 is wrong because an inverted uterus is characterized by profuse vaginal bleeding and maternal collapse Narrow your choice by noting similarity in the use of the word "blood" in the stem and two of the options with "bleeding." Eliminate (1) because the fundus is not boggy, but firm. Which nursing action increases a woman's discomfort during a pelvic examination? Explaining why the examination is being done and what she may expect. Offering the nurse's hand for her to squeeze. Suggesting breathing techniques to help her relax. Asking her to empty her bladder before the examination. Offering your hand to squeeze encourages her to tense her muscles, including the pubococcygeus muscle of the pelvic floor increasing the discomfort of a pelvic examination. Answer 1 is incorrect because explaining that she may expect and the reasons for examination procedures is an appropriate nursing action designed to reduce her anxiety and tension. Answer 3 is wrong because suggesting and demonstrating breathing techniques is an appropriate nursing action designed to assist her to relax during the procedures. Answer 4 is wrong because asking her to empty her bladder is appropriate anticipatory guidance designed to reduce the stress of the pelvic examination Visualize what happens to the pelvic area when squeezing a hand; this may help you choose the best answer (i.e., what is helpful). Which finding is inconsistent with an 8-week gestation? Chadwick's sign. Hegar's sign. Goodell's sign. Ballottement. The finding of ballottement is more consistent with a pregnancy of 19 or more weeks. Answer 1 is incorrect because Chadwick's sign (bluish discoloration of the vagina) is usually present at 8 weeks of gestation. Answer 2 is wrong because Hegar's sign (softening of the lower uterine segment) is present by 8 weeks. Answer 3 is wrong because Goodell's sign (softening of the cervix) is usually present at this point in gestation Key words are "inconsistent" and "8 weeks of gestation." Three of the signs are present around 8 weeks; one is much later. Four hours after birth, a newborn begins to show signs of respiratory distress. This newborn's history includes 42 weeks of gestation and two episodes of late FHR decelerations during labor. Which of the following should the nurse suspect? Aspiration syndrome. RDS. Oxygen toxicity. Bronchopulmonary dysplasia. Aspiration syndrome occurs commonly among post-term newborns, especially if they are postmature. Hypoxia accompanies progressive placental insufficiency (evidenced by late FHR decelerations) with advancing gestational age. Physiological response to hypoxia is relaxation of the anal sphincter, with release of meconium into amniotic fluid, and the fetal gasp reflex. Answer 2 is incorrect because RDS is associated most commonly with prematurity and insufficient pulmonary surfactant. Answer 3 is wrong because oxygen toxicity occurs after a period of oxygen therapy. Answer 4 is wrong because bronchopulmonary dysplasia (BPD) is associated with prolonged administration of oxygen at high concentrations; the time since birth is too short for the baby to develop BPD The key element is a time factor: 42 weeks = postmaturity. Plans to minimize symptoms of physiologic adaptations to pregnancy include suggesting which of the following? High-carbohydrate diet and decreased fluid intake, to stimulate peristalsis. Pelvic rock-and-tilt exercises, to increase tone of her abdominal muscles. Symptomatic relief by over-the-counter antacids and mild laxatives. Increased fluid intake and small, frequent, high-bulk meals. Increasing fluid and roughage intake will reduce symptoms of constipation. Answer 1 is incorrect because a high-carbohydrate diet and reduced fluid intake may make constipation worse. Answer 2 is wrong because exercise does not counteract the effects of progesterone. Answer 3 is wrong because many over-the-counter antacids contain sodium and frequent use of laxatives may result in further loss of tone, leading to constipation Because constipation is a common discomfort of pregnancy, focus on (1) and (4), which relate to diet. Next, eliminate (1) because of decreased fluid. Which theory provides the basis for the nurse's explanation and teaching regarding gestational diabetes? There is an anti-insulin effect of human placental lactogen (HPL). There is a proinsulin effect of HPL. Increased maternal tissue sensitivity to insulin. Diabetes is unrelated to pregnancy; size and production of the islets of Langerhans are unaffected. The anti-insulin effects of the placental hormone HPL (a growth hormone) and reduced maternal tissue sensitivity to insulin often may result in development of gestational diabetes in women who previously had no symptoms of diabetes. Answer 2 is wrong because the effect of HPL is antagonistic to insulin, not proinsulin. Answer 3 is wrong because there is decreased maternal tissue sensitivity to insulin. Answer 4 is wrong because the size and production of the islets of Langerhans increase during pregnancy Understand the mechanisms and risks for glucose intolerance/insulin resistance in pregnancy. To help remember the insulin requirements in pregnancy, use the following memory aid: trimester one:?-; trimester two: ?; trimester three: ?;postpartum:?; A new mother wants to breastfeed. She has had no previous experience or instruction. Which of the following should the nurse include in teaching her about good nipple care? Washing nipples and breasts every day with soap and water to prevent infection. Keeping nipples clean with warm water and then air-drying to reduce irritation. Applying dilute alcohol solution to nipples after each feeding, to toughen them. Covering the nipples with a plastic-lined breast shield to protect clothing. Nipples cleansed with plain water and air-dried carefully are less likely to develop fissures. Answer 1 is incorrect because soap is drying and removes natural oils. Answer 3 is incorrect because alcohol would be too drying and promotes fissure development. Answer 4 is wrong because a plastic shield would retain body heat and moisture, irritating nipples Three options have incorrect information. Eliminate the two options that may be too drying (soap, alcohol). Go for "water and air." A woman in labor is becoming more serious, evidences a malar flush, and tends to hyperventilate with contractions. These signs occur most commonly during which phase? Latent. Active. Transitional. Pushing. These behaviors are characteristic of the active phase of the first stage of labor, at about 5 cm dilation. Answer 1 is wrong because women are more excited and relaxed during the latent phase when labor is less uncomfortable. Answer 3 is wrong because behaviors during transition reveal the woman's focus on completing the process rapidly; irritability is common. Answer 4 is wrong because the woman uses sustained inhalations to increase the force of her pushing Recall stages and phases of labor and expected patient behaviors: latent—more relaxed, less uncomfortable; active—hyperventilation, flushed; transitional— irritable. A newborn who weighed 7 lb at birth now weighs 6 lb 8 oz. Implementing health teaching, the nurse tells the mother the percentage of birthweight usually lost by normal, healthy babies. Which of the following represents the maximum amount of normal weight loss for this newborn? 6oz(170g). 8oz(227g). 11 oz(317g). 16oz(454g). Term infants may lose 5-10% of their birth weight. Arithmetic: 7 X 16 oz = 112 oz; 10% of 112 = 11.2 oz (317.5 g). Answers 1,2, and 4 are wrong because of inaccurate computation Accurate multiplication (16 oz = 1 pound) is the key. Remember that 5-10% loss is OK. For which reason must a preeclamptic woman be carefully assessed for fluid intake and urine output? Oliguria is a grave sign. Daily intake should never exceed 2000 mL. Sudden diuresis can precipitate convulsion. If urine output is less than 100 mL/4 hr, repeat dose of magnesium sulfate is needed. Oliguria is an ominous sign in preeclampsia. Answer 2 is incorrect because daily intake is individualized for the preeclamptic woman. Answer 3 is wrong because sudden diuresis is a good prognostic sign. Answer 4 is wrong because urinary output must equal or exceed 120 mL/4 hr before magnesium sulfate, if needed, can be given again Scanty urine is a critical finding; lots of urine (diuresis) is a good sign (3). A new mother saturates her perineal pad in 15 minutes. Her fundus is firm and smooth, and there is a constant trickle of blood from the vagina No dots can he expressed when the fundus is massaged. Which action should the nurse take immediately? Notify the physician because she needs surgery. Notify the physician because the site of her bleeding must be located. Administer oxytocin according to prn order. Reapply perineal pad and evaluate bleeding in 15 minutes. The laceration must be located and treated before bleeding will stop. Answer 1 is incorrect because, if the laceration is accessible, bleeding may be controlled by insertion of vaginal packing. Answer 3 is wrong because bleeding is not related to uterine atony. Answer 4 is wrong because perineal pressure would be ineffective with a vaginal laceration Choose the answer that would be the first action; think assessment (by the MD) as the priority (i.e., "must be located"). If a pregnant woman's vaginal discharge is thick, white, cheeselike, and pruritic, the nurse's therapeutic and educational actions should be based on which of the following? No action needed. This is normal leukorrhea of pregnancy. Metronidazole (Flagyl) is the drug of choice to treat this condition. Even if untreated, this condition presents no hazard to the neonate. This condition is more likely to occur in women who are pregnant or taking oral contraceptives or antibiotics or who are diabetic. Her discharge is characteristic of a monilial (yeast) infection. This infection is more common in women whose vaginal pH has changed because of pregnancy or diabetes or who are taking oral contraceptives. Antibiotic therapy is also associated with increased risk for developing an infection by Candida albicans. Answer 1 is incorrect because normal leukorrhea associated with pregnancy is thin, colorless, and nonpruritic. Answer 2 is wrong because mycostatin (Nystatin) is the drug of choice for treating vaginal yeast infections; metronidazole (Flagyl) is used in treating trichomonal infections. Answer 3 is wrong because, if present during the baby's birth, this organism causes neonatal thrush Because these are the signs and symptoms of monilial infection, you can eliminate the first three options; this is not normal (1). The drug in Answer 2 is incorrect, and there is a hazard to the neonate (3). If a pregnant woman's last normal menstrual period started August 5, her EDB is: May 12. May 30. June 8. June 12. Using Nägele's rule to calculate the EDB, the correct date is arrived at by taking the date of the first day of the last menstrual period (LMP) and subtracting 3 months and adding 7 days. Answer 2 is wrong because 7 days have been subtracted from her LMP. Answer 3 is wrong because calculations have erroneously included August as one of 3 months, and only 3 days have been added to the date of LMP. Answer 4 is wrong because, although calculations added 7 days, August was again erroneously included as one of the 3 months subtracted Use the memory aid for Nägele's formula: EDB = LMP - 3 months + 7 days. A pregnant woman complains, "I waddle like a duck, and after even a short walk, my back and legs ache. Why? What can I do about that?" Which of the following provides the basis for appropriate health teaching? Relaxation of pelvic joint articulations and strain on supporting muscles due to the growing uterus cause these symptoms. An increased metabolic rate in pregnancy results in excess production of lactic acid in back muscles. Progesterone causes striated muscle stretching and pain on motion. Decreased venous return from the legs and the pressure of the heavy uterus cause waddling and discomfort. Shitting the center of gravity to compensate for the weight of the growing uterus places strain on supporting musculature and contributes to low-back ache during pregnancy; relaxation of joint articulations is responsible for the waddling gait. Answer 2 is wrong because vigorous exercise contributes to the production of lactic acid; the increased metabolic rate during pregnancy has no effect. Answer 3 is wrong because progesterone affects smooth muscle. Answer 4 is wrong because decreased venous return and pressure from the growing uterus contribute to development of varicosities Only (1) and (4) address both the "waddle" and back leg discomfort. Eliminate (4) because the explanation is for varicosities. Which action should the nurse recommend to reduce normal discomforts of pregnancy such as duck-waddle walk and back and leg ache? Avoid walking whenever possible; get bed rest in side-lying Sims' position several times daily. Perform pelvic tilt-and-rock exercises; get rest whenever possible, legs elevated. Wear a maternity girdle to provide support. Increase calcium intake, perform stretching exercises, and rest frequently during the day. Exercises like the pelvic tilt slide and rock strengthen the abdominal and back muscles, which support the mother in an erect position—and the growing uterus; rest while elevating the legs reduces stress on these muscles and the legs and decreases symptoms. Answer 1 is incorrect because walking is an excellent mild exercise recommended for the pregnant woman. Answer 3 is wrong because a girdle may contribute to decreased venous return from the extremities. Answer 4 is wrong because symptoms are due to strain on supporting muscles and are unrelated to the level of circulating calcium Choose the option that results in muscle strengthening. A new mother is distressed because her baby looks a little yellow. She says, "The other nurse said she has 'physical' jaundice. What's that? Is it bad?" The nurse's explanation is based on knowledge of the normal physiological changes of the newborn. Which of the following is responsible for a newborn's physiologic jaundice? Liver immaturity and fetal polycythemia. Oliguria and kidney immaturity. Infection. Dehydration. Physiologic jaundice is related to inability of the liver to conjugate bilirubin liberated by normal hemolysis of fetal RBCs and polycythemia. Answer 2 is incorrect because jaundice associated with kidney immaturity is pathological. Answer 3 is wrong because jaundice occurring secondary to infection is also pathological. Answer 4 is wrong because, although dehydration may be associated with the jaundice, it also is pathological Identify physiologic vs. pathologic jaundice. Pathological is not normal. Note the words in the stem: "normal" physiological. Liver immaturity is not pathological, hut oliguria, infection, and dehydration are. When discussing common complaints arising from normal maternal adaptations to pregnancy, which normal physiologic change has greater implications for the woman with a history of diabetes mellitus and requires more teaching about warning signs and symptoms needing prompt medical evaluation? Increased venous pressure in lower extremities. Placental production of HPL (human placental lactogen). Increased cardiac output. Relaxation of the cardiac sphincter. Human placental lactogen (HPL) is an insulin antagonist and may complicate management of diabetes during pregnancy. Answer 1 is incorrect because fatigue and varicosities are common complaints associated with decreased venous return from the lower extremities. Answer 3 is wrong because increased cardiac output places additional work on the heart. Answer 4 is wrong because relaxation of the cardiac sphincter is associated with heartburn and gastric reflux By understanding the functions of HPL, you can see the connection with diabetes. Answers 3 and 4 deal with cardiac problems, not diabetes Close observation and continuous nursing assessment of a woman with severe preeclampsia are necessary to facilitate prompt identification and management of which of the following? Abruptio placentae. Placenta previa. Hydramnios. Hyperemesis gravidarum. Abruptio placentae may be a complication of severe preeclampsia and places both mother and fetus in jeopardy. Answer 2 is incorrect because placenta previa is due to low implantation, not pathophysiological changes in preeclampsia. Answer 3 is wrong because hydramnios is most commonly associated with maternal diabetes, and although it may coexist with preeclampsia, it is not a contributing factor. Answer 4 is wrong because hyperemesis gravidarum occurs earlier in pregnancy and is not associated with development or progression of preeclampsia By recalling the definition of the four terms, identify the condition for which severe preeclampsia is a risk factor. A pregnant woman is admitted for evaluation of her cardiac status at 24 weeks of gestation. During the evening, she complains of dyspnea and shortness of breath while ambulating. She has a moist cough. Her physician orders complete bed rest. Which nursing intervention is most appropriate to prevent further deterioration of her cardiac condition? Place her in Trendelenburg position to encourage venous return to the heart. Assist her with activities of daily living to reduce energy expenditures. Encourage frequent coughing and deep breathing to prevent pulmonary complications of immobility. Initiate a regimen of lower-limb exercises to prevent venous stasis and leg thrombosis. Activities of daily living increase energy expenditures and may contribute to further cardiac decompensation. Answer 1 is incorrect because dyspnea and shortness of breath will be exacerbated in Trendelenburg position. Answer 3 is incorrect because any activity that causes her to perform a Valsalva maneuver (coughing) will cause a sudden increase in blood return to the heart, which is contraindicated in cardiac disease. Answer 4 is incorrect because the major goal of care is to reduce all energy expenditures Look at the verbs: "place," "assist," "encourage," "initiate." Choose "assist" for preventing further cardiac decompensation. A new mother tells the nurse she is breastfeeding because she can't stand the thought of the baby being vaccinated. Which response demonstrates effective health teaching? That's great. Vaccinations aren't needed if you breastfeed him. Oh, you still need to have him vaccinated against DPT, measles, and polio before he is 6 months old. You can only give temporary protection to the infant against the diseases you have had yourself. The most protection comes from colostrum just after birth. Unfortunately, you didn't start feeding him right away. Only disease-specific antibodies produced by the mother in response to that infection can be produced through breast milk to the baby. Answer 1 is incorrect because vaccinations would be needed to develop active immunity. Answer 2 is wrong because measles vaccination is not effective if given before 1 year of age. Answer 4 is wrong because maternal antibodies confer only short-lived passive immunity Understand the effects of antibodies on the infant who is breastfeeding. When a question asks for effective health teaching, three of the answers will not be accurate information. Choose the one that is. A woman says, "My doctor says I'm 5 months (20 weeks) pregnant. What does my baby look like now?" The nurse's response is based on knowledge of normal fetal development. Which of the following describes the average fetus at 20 weeks of gestation? Viable, able to survive outside of the uterus with minimal assistance. About 10 inches long, weight about 10 oz, and covered with fine, downy hair and vernix. Beginning sex differentiation, kidney function, and detectable movements. Shedding lanugo and vernix, growing rapidly, weighs about 1'/, pounds. These are the characteristics of the fetus at 20 weeks of gestation (22 menstrual weeks). Answer 1 is incorrect because, although 20 weeks has been identified as viability, most such fetuses are too immature to survive independent extrauterine existence successfully. Answer 3 is wrong because sex differentiation begins at conception and is discernible at 12 weeks, and kidneys begin secreting urine at 11 weeks. Answer 4 is wrong because the fetus begins to exhibit these characteristics at 31 weeks Remember: 10 inches, 10 oz at 20 weeks. Review fetal development by trimester of pregnancy In discussing "dos and don'ts," which health teaching aspect should be emphasized as important for health maintenance during pregnancy? Keeping appointments for prenatal visits, remembering to ask questions when necessary, and following the medical/nursing recommendations. Making preparation for childbirth classes. Moderate exercise, high-carbohydrate diet, and adequate rest. Taking multivitamins and iron, drinking six glasses of milk daily, and minimizing physical exertion. The most important factor in reducing morbidity and mortality associated with pregnancy is close health supervision and prompt management of emerging problems and complications. Answer 2 is incorrect because the primary goal of prenatal classes is to prepare the couple for labor and birth. Answer 3 is wrong because high-protein diets are recommended during pregnancy to reduce the possibility of preeclampsia. Answer 4 is wrong because the pregnant woman should drink 1 quart of milk and increase her intake during lactation The best option relates to goals during pregnancy, not specifically for labor and delivery, as in (2), for reduction of morbidity and mortality. When an answer has multiple points, be sure to read each of these carefully because not all points in the option are correct, such as (3) and (4), making the option only partially accurate. Which response is appropriate to give to a pregnant woman who is worried about having urinary frequency? Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes. Frequency is due to bladder irritation from concentrated urine and is normal in pregnancy. Increase your daily fluid intake to 3000 mL. Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1000 mL daily. Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercises will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding. Answer 1 is incorrect because progesterone does not cause irritability of the bladder sphincter. Answer 2 is wrong because frequency in early and late pregnancy is due to pressure on the bladder from the growing uterus. Answer 3 is wrong because hydration is important in maintaining normal digestion and nutrient transport to body cells, removing wastes, and regulating body temperature. During pregnancy, eight 8 oz glasses of fluid daily are recommended When the question asks for an appropriate response, eliminate the theoretically incorrect responses first. Understand the effects of progesterone on smooth muscle (specifically the bladder). As a woman progresses through labor, she becomes increasingly irritable with her partner, complaining of lower-backpain and fatigue. Which nursing intervention is most appropriate now? Have the woman turn on her side and give her a back rub. Ask her if she would like the nurse to get an order for something for her discomfort. Reassure the partner that irritability is normal, and teach the partner to apply sacral pressure with contractions. Send the partner for a coffee break, and encourage the woman to try to get some rest. Reassurance that her behavior is normal for this point in labor helps reduce the partner's feelings of guilt and help lessness and fosters the sense of a mutual, shared experience; sacral pressure reduces her discomfort. Answer 1 is wrong because it does not address the partner's feelings. Answer 2 is wrong because it does not facilitate the shared experience and may result in feelings of failure in some women. Answer4 is wrong because she is progressing well and needs/wants her partner's support Note the pattern in the answers: three options do not involve the partner; one option does. In this case, choose the option that is different. At 37 weeks, a pregnant woman calls the office to say she awakened in a pool of blood and is dizzy and nauseated. She denies any abdominal pain or cramping. On the basis of this assessment, the nurse suggests she go to the hospital immediately. The nurse established a nursing diagnosis of high risk for fluid volume deficit associated with which of the following? Placenta previa. Abruptio placentae. Preeclampsia. Uterine rupture. Painless vaginal bleeding is associated with placenta pre via. Answer 2 is wrong because abdominal pain and a tense abdomen are signs of possible abruptio placentae. Answer 3 is wrong because painless vaginal bleeding is not indicative of preeclampsia. Answer 4 is wrong because the uterine rupture is characterized by sudden sharp abdominal pain, signs of internal bleeding, and shock The key point is painless. Recall the differences between signs and symptoms of placenta previa and abruptio placentae. Answers 2 and 4 involve pain and can be eliminated, and for one condition (3) pain is not relevant. An expectant father says, "My wife is a heavy smoker—three packs a day. She won't listen to me. Will you talk to her?" Which nursing approach is appropriate to this problem? Tell the woman that, if she continues to smoke that much, the baby will be small and have a greater chance of childhood respiratory infections. Teach the woman to substitute snacking on cheese, dried apricots, or raisins to curb her desire to smoke. Discuss current thoughts about the effects of smoking during pregnancy with the woman, and ask her if she can think of ways to cut down. Ask the woman how she plans to cut down to 10 cigarettes daily. Encouraging her to consider ways to reduce her smoking implies your respect for her ability to deal with the problem and encourages her active participation in her own pregnancy-related care. Answer 1 is incorrect because such comments generate guilt and may threaten her self-image. Answer 2 is wrong because telling her to substitute even "good foods" implies lark of respect for her judgment and assumes that she will comply with your choices for her behavior. Answer 4 is wrong because it implies she has no choice in the matter; patient goals are best established mutually "Discuss" is better than "tell" or "teach" in this case. Which signs and symptoms require immediate medical evaluation during pregnancy? Excessive saliva, "bumps" around the areolae, and increased vaginal mucus. Fatigue, nausea, and urinary frequency at any time during pregnancy. Ankle edema, enlarging varicosities, and heartburn. Severe abdominal pain or fluid discharge from the vagina. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placentae; fluid discharge from the vagina may indicate pre-mature rupture of the membranes. Answer 1 is incorrect because ptyalism, elevated Montgomery tubercles, and leukorrhea arc normal physiological responses during pregnancy. Answer 2 is wrong because fatigue, nausea, and frequency are normal in early pregnancy. Answer 3 is wrong because ankle edema, varicosities, and heartburn are normal during pregnancy Select "severe pain" as the most critical finding. Know the signs of the most serious complications during pregnancy. Which signs and symptoms during pregnancy should the nurse teach as possible warning signs of potential problems? Edema of the lower extremities, vulvar varices, and copious, clear vaginal discharge. Heartburn, shortness of breath, change in appetite. Leg cramps, back pain, and increased pigmentation over the bridge of the nose and the cheeks. Headache, visual disturbances, or feeling of fullness in face and hands. Headache and feeling of fullness in face and hands may indicate preeclampsia. Answer 1 is wrong because pedal edema, varicosities, and vaginal discharge are related to decreased venous return and increased vascularity in pregnancy. Answer 2 is wrong because heartburn, shortness of breath, and change in appetite are normal responses in pregnancy. Answer 3 is wrong because leg cramps, low-backache, and chloasma are associated with normal physiological changes of pregnancy Distinguish between common normal discomforts of pregnancy and more serious complications. Prioritize critical findings. The pregnant woman who would likely be given a "trial of labor" for vaginal birth after cesarean (VBAC) is one who had a first: Cesarean through a classic uterine incision because of severe fetal distress. Low transverse cesarean for breech presentation; this pregnancy is in vertex presentation. Cesarean for fetopelvic disproportion. Low transverse cesarean for active vaginal/perineal herpes infection; culture at 39 weeks this pregnancy was positive for herpes. The reason for the first cesarean was a breech presentation, and that is not present in this pregnancy. Also, a low transverse uterine incision presents only a very slight risk for uterine rupture with subsequent VBAC deliveries. Answer 1 is incorrect because the classic vertical incision through the uterus (and subsequent scar) is considered to weaken the uterus and compromise its ability to withstand stretching and contracting. Answer 3 is incorrect because the original cause (fetopelvic disproportion) remains. Answer 4 is incorrect because an infant may acquire herpes during passage through an infected birth canal Visualize the common uterine incision used and why it would pose the greatest risk for uterine rupture. Eliminate Answer 3 because the same condition exists again and eliminate Answer 4 because there is maternal infection now. Review the risks of cesarean birth, and specifically the risks of a vaginal birth after a previous cesarean. A woman with a history of diabetes may require hospitalization during her pregnancy for treatment of any problems associated with her pregnancy or for diagnostic tests. When asked to verbalize her understanding of the discussion, which of this woman's responses indicates a need for further health teaching? Pregnancy may change the amount of insulin 1 need for regulation of my diabetes. I may need to be hospitalized to evaluate how well my placenta is functioning. If this awful morning sickness keeps up, the doctor may put me in to control it. The doctor may need to take a sample of my water (amniocentesis) to see if the baby has the gene for diabetes. Amniocentesis does not show whether the fetus is a potential diabetic, but it may be performed on diabetic women to test for fetal lung maturity. Answer 1 is wrong because her statement indicates understanding of the inter relationship between her pregnancy and her diabetes. Answer 2 is wrong because pregnant diabetics may be hospitalized for testing for placental function. Answer 3 is wrong because nausea and vomiting in the pregnant diabetic may lead to acidosis When a question asks for "need for further health teaching," the best answer will have an incorrect statement. Review the goals of care for a pregnant diabetic. Assessment findings at 16 weeks of gestation include marked chloasma and secondary pigmented areolae; in addition, the woman's umbilicus is flush with her skin. During which trimester are these physical changes of pregnancy commonly found? First. Second. Third. Fourth. Chloasma, secondary pigmented areolae, and umbilicus flush with the skin are characteristic changes in the second trimester. Answer 1 is wrong because these signs are not present during the normal first trimester. Answer 3 is wrong because, although present during the third trimester, these changes begin during the second. Answer 4 is wrong because these signs diminish during the fourth trimester Think skin (chloasma, pigmented areola) = second. Note the word "secondary" in the stem is similar to "second" in (2). A new mother tells the nurse, "I am afraid the baby will have something wrong with her because I was bad while I was carrying her. Is she really okay?" If observed, which of the following would the nurse note as unusual in a newborn girl? Enlarged breasts and some pink drainage from the baby's vagina. A dark line between the baby's umbilicus and symphysis. Little "blackheads" covering her nose and chin. A dark discoloration over her sacrum and lower back. is unusual because milia (unopened sebaceous glands) look like whiteheads. Answer 1 is typical because enlarged breasts and pink spotting (pseudomenstruation) are effects of high circulating levels of maternal hormones. Answer 2 is typical because the linea nigra is evident due to maternal hormones. Answer 4 is typical because "mongolian spots" are found on the lower back and sacrum of darker-skinned people Test-taking tip Look for what is not typical after recalling normal assessment findings for a full-term neonate girl. An infertility assessment begins with a thorough health history. Which factor is likely to be implicated in female infertility? Moderate alcohol intake. Menstrual cycle of 26 to 28 days. History of PID. Past use of diaphragm and spermicide for contraception. PID is associated with adhesions and blockage of the fallopian tubes, preventing transport and joining of the ovum and sperm. Answer 1 is incorrect because moderate alcohol intake is not implicated in female infertility. Answer 2 is incorrect because a normal menstrual cycle is not associated with infertility. Answer 4 is incorrect because use of a diaphragm and spermicidal jelly is not implicated in infertility Look for the risk factor that is a common cause of female infertility. Which nursing intervention is most likely to be included in the plan of care for a woman with heart disease during the first postpartum day? Push oral and IV fluid to stimulate diuresis and prevent fluid volume overload. Encourage early ambulation and exercise to reduce the risk of thrombophlebitis. Monitor vital signs, skin color, and pulmonary status to identify cardiac decompensation. Encourage her to defer breastfeeding on the first day to reduce the cardiac workload. is correct because major cardiovascular changes that occur with the termination of pregnancy can result in sudden cardiac decompensation in the first postpartum day. Answer 1 is incorrect because pushing fluids can result in fluid volume overload and cardiac decompensation. Answer 2 is incorrect because the postpartum woman with heart disease is encouraged to rest on the first day to minimize cardiac stressors while major cardiovascular changes occur. Answer 4 is incorrect because breastfeeding is not contraindicated The emphasis is on a time factor: first postpartum day and the risks caused by heart disease during pregnancy and lactation. The nursing assessment of a newborn reveals a lump on one side of the head that does not cross suture lines. Which of the following should the nurse tell the mother is the cause of the lump? Bleeding between the periosteum and parietal bone occurred due to pressure against the bony pelvis during birth. Edema of the scalp occurred due to pressure of the vertex against the cervix during the first stage of labor. Intracranial hemorrhage occurred due to pressure from the forceps during birth. Simple swelling of a common hemangioma occurred due to prolonged pushing in the second stage of labor. Cephalohematoma is caused by subperiosteal bleeding, and the "lump" is limited by the suture lines. Answer 2 is incorrect because edema of the scalp is caput succedaneum. Answer 3 is wrong because a cephalohematoma is outside the skull. Answer 4 is wrong because hemangiomas are benign blood vessel tumors In this question, choose the answer that gives information but does not diagnose, for example, Answers 3 and 4. Recall where the problem is (i.e., outside of the skull and whether it crosses the suture line) to help focus on the difference between cephalohematoma and caput succedaneum. Assessing for the normal psychological changes in the third trimester, the nurse would expect a pregnant woman to exhibit which normal behavior? Ambivalence about the pregnancy. Eagerness to begin Lamaze classes. Fantasizing about her child. Withdrawal from other relationships. During the third trimester, the mother becomes ready to begin learning techniques for her use during labor. Answer 1 is wrong because ambivalence about the pregnancy is usually seen in early pregnancy. Answer 3 is wrong because fantasizing is most typical during the second trimester. Answer 4 is wrong because the period of introspection and introversion occurs in the second trimester Time-frame is the clue: third trimester. Three of the options occur earlier. Choose "eagerness" over "fantasizing." Note that the other two options, "ambivalence" (1) and "withdrawal" (4) are problematic. "Eagerness" comes through in the end (third trimester). In reviewing with a pregnant woman those symptoms that require prompt medical evaluation, which of the following would the nurse include? Increasing pedal edema. Feelings of dizziness on arising. Epigastric pain. Spotting within 24 hours of vaginal examination. Epigastric pain is associated with edema of the liver capsule in preeclampsia. Answer 1 is incorrect because dependent edema is common in late pregnancy, due to reduced venous return from the lower extremities. Answer 2 is wrong because orthostatic hypotension may be a common occurrence during the third trimester. Answer 4 is wrong because brown spotting is a normal finding within 24 hours of vaginal examination, due to the increased friability of the cervix during pregnancy Think "most critical findings." "Prompt" = urgent. Pain is critical and urgent because of the signs/symptoms of preeclampsia. A pregnant woman's history reveals a pregnancy at age 15 that was terminated by elective abortion at 10 weeks, birth of twin girls at 37 weeks, and a spontaneous abortion at 12 weeks last year. Analyzing these data, the nurse selects which of the following to describe her present gravidity and parity? Gravida 5 para 2. Gravida 5 para 1. Gravida 4 para 2. Gravida 4 para 1. Gravidity is defined as the number of pregnancies; she has been pregnant three previous times and is now pregnant for the fourth time. Parity is defined as the number of pregnancies carried to viability (20 weeks since conception; 22 menstrual weeks). The woman has had two pregnancies terminated before viability (abortions) and has carried one pregnancy, which resulted in viable twin girls. Answer 1 is incorrect because this counts the twins as two pregnancies carried to viability. Answer 2 is wrong because, although it correctly identifies the twins as one parity, it counts them as two pregnancies. Answer 3 is wrong because, although it correctly identifies the woman as gravida 4, it counts the twins twice Know definitions of gravida and para and how to determine a woman's obstetric history. Use the acronym GTPAL: G—-Gravida; T—Term; P—Para; A— Abortions; L—living children. The postovulation rise in BBT is due to the high blood level of which hormone? Follicle-stimulating hormone (FSH). Human placental lactogen (HPL). Estrogen. Progesterone. High circulating levels of progesterone released by the corpus luteum are thought to be responsible for the immediate postovulation rise in body temperature. Answer 1 is wrong because FSH is responsible for maturation of the follicle before ovulation. Answer 2 is wrong because HPL is produced by the placenta and is not present at this time. Answer 3 is wrong because estrogen is not implicated in the rise in body temperature postovulation Think P's: postpovulation = progesterone. Recall female hormones and their functions related to the menstrual cycle. Nursing assessment of a woman in labor notes marked introspection, irritability, and inability to focus. She is diaphoretic, and cries, "I can't take it!" These behaviors are characteristic of which stage or phase of labor? Active phase. Transitional phase. Second stage. Third stage. These behaviors are characteristic of the transitional phase of labor, approaching 10 cm dilation. Answer 1 is incorrect because the woman shows a more intense, serious demeanor and may hyperventilate with contractions in the active phase. Answer 3 is incorrect because the second stage of labor is characterized by expulsive efforts. Answer 4 is incorrect because in the third stage the placenta is expelled and the woman is euphoric and focuses on the infant The three Ts (introspection, irritability, inability to...) are indicative of transition. Recall the phases and stages of labor and expected patient responses. During the last month of pregnancy, a pregnant woman comments, "I am sick and tired of this whole thing. I can hardly wait for it to be over." Comparing her statement to the normal psychological responses of other pregnant women during the last trimester, the nurse responds appropriately with which statement? I think you should see the psychiatric social worker. You should be feeling more positive about the baby by now. I know exactly how you feel. I've seen it a thousand times. It'll pass. Well, sounds like you're ready for labor. Do you have any questions about your coming labor? Your pregnancy is getting a bit tiresome and the time is dragging? She does need support for her feelings at this point in pregnancy and validation that they are normal. Answer 1 is incorrect because she is evidencing only normal responses to late pregnancy. Answer 2 is wrong because such statements tend to inhibit further exploration of her feelings and convey that such feelings are unimportant to the nurse. Answer 3 is wrong because it neither validates the normalcy of her feelings nor encourages any further ventilation Choose the most open-ended communication approach. The goal is to be supportive of expected psychological changes in the third trimester. A 16-year-old, single woman wants to give her baby up for adoption. Which plan will be of most help to her? Provide a safe environment, encourage ventilation of her feelings, give no answers or direction so that she makes her own decisions. Provide the information she needs to understand the situation, place it in perspective in terms of her life goals, and begin to plan for the future. Support her choice whatever her decision. Help her see ways of not making the same error again so she can grow in self-esteem and self-respect. 2 is correct because the nurse can best fulfill the role of advocate by providing all essential information the adolescent needs to make informed decisions; this allows opportunity for introspection and growth. Answer 1 is incorrect because adolescents require and desire some guidance or assistance with major life decisions from supportive adults. Answer 3 is incorrect because it may not be appropriate or ethical to support some decisions the adolescent makes. Answer 4 is incorrect because such actions are judgmental, tend to destroy rapport, and nullify possible growth Select the answer that describes the advocacy role of the nurse in patient decision making (i.e., providing information for informed decision making by the patient). The physician determines that a woman's inability to conceive is due to anovulatory cycles and discusses treatment options. An expected emotional response to this diagnosis and possible treatment indicating that the woman understands the underlying problem would be: Guilt for past sexual behaviors. Grief because she will never be able to conceive. Fears regarding the need for corrective surgery. Anxiety regarding the side effects of clomiphen citrate (Clomid). 4 is correct because clomiphen citrate (Clomid) is used in infertility caused by anovulatory cycles. It increases the secretion of FSH and LH and stimulates ovulation. Side effects include vasomotor flushes, bloating, nausea, vomiting, headache, hair loss, and visual disturbances. Answer 1 is incorrect because anovulatory cycles are not caused by past patterns of sexual behavior. Answer 2 is incorrect because many women who experience anovulatory cycles may successfully conceive after treatment. Answer 3 is incorrect because anovulatory cycles are not treated with surgical intervention The key word is treatment option. Narrow your focus to (3) or (4) because they are possible treatments for female infertility. Eliminate (3) because it is not a treatment for anovulatory cycles. A couple has been unable to conceive; the man is being evaluated for possible problems. A semen analysis is ordered. Which instruction regarding collection of a sperm specimen is appropriate? Collect specimen at night, refrigerate, and bring to clinic the next morning. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. Collect specimen after 48 to 72 hours of abstinence and bring to clinic within 2 hours. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. 3 is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48 to 72 hours. Answer 1 is incorrect because an accurate sperm count and evaluation of motility require that the specimen be examined within 2 hours. Refrigeration will kill sperm. Answer 2 is incorrect because 24 hours of abstinence is insufficient for adequate production of sperm. Answer 4 is incorrect because ice will reduce motility and kill sperm Think: best is more rest (abstinence). Note the answer is time related: when in relation to abstinence, and how—that is, avoid ice, refrigeration as in Answers 1 and 4. In health teaching for women who desire "natural child birth," which statement should the nurse explain is a myth? Medication may be used to reduce tension and pain during labor. Labor and birth under Lamaze techniques are almost painless. Labor is easier for women who are self assured, relaxed, and cooperative during the process. Preparation for childbirth may include body-building exercises, breathing techniques, and comfort aids. Lamaze techniques, although helpful, do not guarantee freedom from discomfort throughout the labor process. Answer 1 is incorrect because medication may be used to assist the woman in controlling her response to the child-bearing process and to facilitate a successful experience. Answer 3 is wrong because labor is easier for the woman who understands what is happening and is able to relax and cooperate. Answer 4 is wrong because many preparation-for-childbirth courses use these aids. When the question asks which one is a myth, choose the incorrect answer. A pregnant woman is told to increase her intake of foods high in iron. Which of the following foods should the nurse suggest as being the best source of iron? Lean red meat. Nuts. Shellfish. Dairy products. Red meats, egg yolks, and organ meats are the best sources of iron. Answers 2,3, and 4 are incorrect because they do not contain as much iron as red meat Knowing the best (highest) food sources of iron will help you choose the best answer. Health teaching during the prenatal period should emphasize that expectant primigravida mothers should go to the hospital when which pattern is evident? Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps. Although instructions vary among birth centers, primi-gravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger. Answer 1 is incorrect because she should have sought care earlier. Answer 2 is incorrect because she should have sought care earlier. Rectal pressure may be a sign of impending birth. Answer 4 is incorrect because this pattern may reflect "false labor" or very early latent phase labor Think time factor: when, how long, "too late" vs. "too soon." Be aware of how to distinguish between false and true labor. Assessment findings of Leopold's maneuvers reveal a soft, rounded mass in the fundus, irregular nodules on the rightside, and a hard prominence on the right, just above the symphysis. Which of the following accurately describes the fetal presentation and position? Right sacrum posterior (RSP). Left sacrum anterior (LSA). Right occiput posterior (ROP). Left occiput anterior (LOA). Of the choices given, if the breech is in the fundus, the occiput must be the presenting part; if the irregular nodules (elbows, knees, feet) are on the right side, the fetal back is to the maternal left. Answer 1 is incorrect because the "S" refers to the fetal sacrum and describes a breech presentation. Answer 2 is wrong because this also describes a breech presentation. Answer 3 is wrong because the fetal back is on the maternal left side, as is the occiput Visualize the fetal position described to help you choose the answer with the head (occiput) presenting. If the fetus is LOA, in which maternal location should the nurse anticipate finding the fetal heart tones (FHTs)? Below the umbilicus on the left side. Below the umbilicus on the right side. Above the umbilicus on the left side. Above the umbilicus on the right side. FHR is heard best through the fetal back, which, in LOA presentations, is below the umbilicus on the maternal left side. Answer 2 is incorrect because the fetal back is on the maternal left. Answer 3 is wrong because, in a vertex presentation, the heart tones are more audible below the umbilicus. Answer 4 is wrong because it describes the placement of FHTs in breech presentations Visualize LOA fetal position and presentation. Think left side (1 and 3) for left occiput anterior (LOA). Which normal assessment finding can the nurse expect in the 34th week of pregnancy? Braxton-Hicks contractions, joint hypermobility, and backache. Dysuria, constipation, hemorrhoids, and lightening. Feeling of tranquility and heightened introspection. Morning sickness, breast tenderness. Braxton-Hicks contractions, hypermobility of joints, and backache are all normal findings at this point in pregnancy. Answer 2 is incorrect because complaints of dysuria should be explored due to the tendency to urinary tract infection in pregnancy. Answer 3 is wrong because a feeling of tranquility and heightened introspection are common in the second trimester. Answer 4 is wrong because these symptoms are most common in the first trimester The clues in the stem are normal and third trimester. Match time-frame (later in pregnancy) with findings (contractions occur later in pregnancy). Which suggestion by the nurse may relieve a pregnant woman's heartburn symptoms? Eat dry bread products before rising. Bend at the knees when reaching down, not at the waist. Hat fewer, larger meals and avoid nibbling. Do pelvic-rock exercise. Bending at the waist facilitates movement of food out of the stomach through a relaxed cardiac sphincter. Answer 1 is incorrect because this is the treatment for morning sickness. Answer 3 is wrong because this tends to aggravate heart burn. Answer 4 is wrong because the pelvic rock relieves backache, not heartburn Eliminate the two options about food and eating. Picture bending from the knees and the effect on cardiac sphincter/diagnosis. A new mother complains of severe lower abdominal cramping after breastfeeding. Which would be the first action taken by the nurse to reduce her discomfort? Administer pain medication as per order. Have her lie on her abdomen with a rolled towel at the level of her fundus. Ask her to walk around for a few minutes. Ask her to empty her bladder. A full bladder may be the major source of her discomfort. Answer 1 is incorrect because medication should be given for minor discomforts only after trying other comfort measures. Answer 2 is wrong because this measure would be used only after she has voided. Answer 3 is wrong because walking does not relieve afterpains First eliminate the two options about position/activity because they are secondary measures. The question asks for the FIRST action. Because the discomfort is felt in the abdomen, choose the option with bladder, which is felt abdominally. In assessing a new mother's response to her son's birth on the first postpartum day, which behavior should the nurse expect to find present? Talkativeness, dependency, passivity. Autonomy and independence. Disinterest in her own body functions. Interest in learning to bathe the baby. Talkativeness, dependency, and passivity are all signs of the "taking-in" phase of the postpartum. Answer 2 is incorrect because the mother needs to have her needs for nurturing and positive reinforcement met at this time. Answer 3 is wrong because she is most interested in her own body functions, her return to normal, and her ability to void and defecate. Answer 4 is wrong because she is not ready to "take hold." Taking-in phase (1) is before taking-hold phase (4). Answers 2 and 3 are theoretically incorrect (according to Reva Rubin's theories) because the opposite of these behaviors occur. Also note two options that are contradictory: dependency (1) vs. independence (2). "Dependency" goes with taking-in. Which technique should the nurse use to assess the frequency, duration, and intensity of uterine contractions? Spread fingers of one hand lightly over the fundus. Move the fingers of one hand over the uterus, pressing into the muscle. Hold fingers and palm of one hand over the area just below the umbilicus. Indent the uterus in several places, during and between contractions. The frequency, duration, and intensity of uterine contractions are assessed by light palpation of the contractile part, i.e., the fundus. Answer 2 is incorrect because moving the hand over the uterus may reduce the accuracy of perceiving contractions; pressure into the muscle may contribute to uterine dysfunction due to manipulation. Answer 3 is wrong because the most contractile part of the uterus is the fundus, not the corpus. Answer 4 is wrong because uterine manipulation between contractions may contribute to uterine dysfunction Picture the actions (the position of the hands). Eliminate Answers 2 and 4 because they may be harmful. Ongoing evaluation of a woman with severe preeclampsia reveals 4 plus deep-tendon patellar reflexes with two beats of clonus. The most appropriate nursing diagnosis related to her current status would be: Pain related to hyperreflexia and clonus. Risk for injury related to possible eclamptic seizures. Impaired physical mobility related to alterations in lower limbs. Sensory/perceptual alterations related to sensory overload. is correct because deep-tendon reflexes indicate the degree of CNS irritability and the potential for seizure activity. Answer 1 is incorrect because hyperreflexia and clonus are not associated with pain or discomfort. Answer 3 is incorrect because hyperreflexia and clonus do not interfere with motor activity in the lower extremities. Answer 4 is incorrect because women with preeclampsia are placed in environments with reduced stimuli to decrease the risk of seizure activity Note the term preeclampsia in the stem and same term "eclamptic" in the correct option (2). Following a birth, after the physician or midwife has cut the cord, and before the baby is given to the mother, which should the nurse do first? Confirm identification of the infant and apply bracelets to mother and infant. Examine the infant for any observable abnormalities. Wrap the infant in a prewarmed blanket and cover the head. Instill prophylactic medication in the infant's eyes. The first priority (beside maintaining a newborn's patent airway) is body temperature. Answer 1 is incorrect because, although important, identification of the newborn may be delayed until after the infant's status is stable. Answer 2 is wrong because the second priority is to note any abnormalities. Answer 4 is wrong because eye prophylaxis may be instilled 2 hours later This question asks you to rank order of priority when all options are correct. Review protocols for newborn care immediately after birth. Which of the following should elicit the Moro reflex in healthy newborns? Sudden or loud noises. Stroking the soles of the feet. Turning a newborn's head to one side. Stroking a newborn's cheek. The Moro reflex occurs in response to sudden stimulation of the newborn's CNS by noise, falling, or jolting. Answer 2 is incorrect because this action elicits the Babinskireflex. Answer 3 is wrong because this action elicits the tonic neck reflex. Answer 4 is wrong because this elicits rooting Match common neurological reflexes of the newborn with the action described in each of the four options. Which assessment of a woman in labor can be determined by vaginal examination? Fetal weight. Cervical dilation. Strength of contractions. Fetal head circumference. Cervical dilation is determined by vaginal examination. Answer 1 is incorrect because fetal weight can only be indirectly estimated by fundal height measurement and sonography. Answer 3 is incorrect because strength of contractions is evaluated by palpation of the uterine fundus. Answer 4 is incorrect because head circumference cannot be determined until after birth Note the relationship between the word "vaginal" in the stem and the correct answer, "cervical." The decision is made to encourage a woman in early labor to walk around the unit for a while, and to then reassess her status. Which assessment distinguishes between true and false labor? Confirmation of spontaneous rupture of membranes. Signs and symptoms of increasing discomfort. Evidence of cervical dilation. Presence of copious bloody vaginal discharge. The criterion used to distinguish true from false labor is evidence of cervical change. Answer 1 is incorrect because spontaneous rupture of membranes can occur before initiation of labor. Answer 2 is incorrect because women who are not in true labor may experience increasing pain due to obstetric complications. Answer 4 is incorrect because copious bloody vaginal discharge can occur without labor (placental problems) True Labor = Cervical Changes (TL = CC). Which of the following should he emphasized as the most important factor in safeguarding cardiac function during pregnancy, for a woman with rheumatic heart disease (RHD)? Adequate exercise. Adequate rest. Low-salt diet. Ferrous sulfate. The most important single factor in maintaining good health for the pregnant woman with heart disease is adequate rest. The woman should have approximately 8-10 hours rest each night and should lie down for 30 minutes after each meal. Answer 1 is incorrect because reduced activity reduces fatigue and supports preservation of cardiac reserve. Answer 3 is wrong because moderate sodium intake (2000 mg) is allowable for the average class I cardiac; nutritional counseling focuses on increasing dietary intake of iron, protein, and essential nutrients to meet the increased demands of pregnancy. Answer 4 is wrong because ferrous sulfate is prescribed to meet the increased demands for hemoglobin synthesis and to combat nutritional anemia Note that two options are contradicting: exercise vs. rest. Think "rest the heart." Late in pregnancy, which of the following is the most likely cause of groin pain that seems worse on the right side? Bladder infection. Constipation. Tension on the round ligament. Beginning of labor. Tension on round ligaments occurs because of the erect human posture and pressure exerted by the growing uterus. Answer 1 is incorrect because bladder infection is accompanied by frequency and dysuria. Answer 2 is wrong because discomfort from constipation is accompanied by other symptoms, and the location of the discomfort differs. Answer 4 is wrong because groin pain is not characteristic of beginning labor The key is time and place. Note that the stem states late pregnancy and location is on the right. A pregnant woman's history reveals one pregnancy, terminated by elective abortion at 10 weeks; birth of twins at 37 weeks; and a spontaneous abortion at 12 weeks. According to the TPAL system, which of the following describes her present parity? 0-2-2-2. 2-0-2-2. 0-1-2-2. 1-0-2-2. 0-1-2-2 describes her present status. She has not carried a pregnancy to term (T); one pregnancy terminated in the preterm (P) birth of twins, two pregnancies ended in abortion (A), and she has two living children (L). Answer 1 is incorrect because only one was a preterm pregnancy. Answer 2 is incorrect because it describes her as having delivered two term infants and no preterm infants. Answer 4 is wrong because it describes her as having carried one pregnancy to term and having no preterm infants Be able to determine an obstetric history using the TPAL system: T—Term; P—Preterm; A— Abortion; L—Living children. Which of the following influences the planning and implementation of postpartum care for a woman who has been diagnosed as severely preeclamptic? Even if she has had no convulsions during the antepartal and intrapartal periods, she remains at risk for convulsions for the first 48 hours postpartum. Preeclampsia is associated only with pregnancy. Once die baby has been born, she is cured. The woman should be advised she may be left with chronic renal damage. Since subsequent pregnancy is extremely hazardous, family planning should be implemented as soon as possible. The possibility of postpartum eclampsia, while high, is often overlooked. Nursing care is planned to maintain ongoing status assessments and minimize environmental stimuli. Answer 2 is wrong because, although the risk decreases subsequent to birth, eclamptic convulsions have been known to occur in the postpartum. Answer 3 is wrong because chronic renal disease is not a sequel to preeclampsia. Answer 4 is wrong because preeclampsia does not necessarily occur in subsequent pregnancies Narrow the choice to two contradictory options: "at risk" (1) vs. "cured" (2). Reduction of risk in the immediate postpartum period is the goal. For which complication of pregnancy is an Rh-negative woman al risk? Spontaneous abortion. Preeclampsia. Maternal anemia. Erythroblastosis fetalis. Even Rh-negative women during their first pregnancy are at some risk for Rh incompatibility; erythroblastosis fetalis results from hemolysis of fetal cells by maternal anti bodies. Answers 1 and 2 are wrong because the Rh-negative woman is not more prone to spontaneous abortion or preeclampsia. Answer 3 is wrong because fetal, not maternal, anemia results from Rh incompatibility The focus should be on the potential risk for the fetus. Understand the pathophysiology of Rh isoimmunization. Which assessment findings indicate 20 weeks of gestation? Lightening, FHR audible by fetoscope, fundus palpable at the umbilicus. Braxton-Hicks contractions, ballottement, and fundus at umbilicus. Quickening noted, FHR audible by fetoscope, fundus at or just below the umbilicus. Goodell's, Hegar's, and Chadwick's signs present, fundus halfway between symphysis and umbilicus. Quickening, audible FHR with fetoscope, and fundal height at just below the umbilicus are present in most women by the 20th week of pregnancy. Answer 1 is wrong because lightening usually occurs at 36-38 weeks of gestation. Answer 2 is wrong because Braxton-Hicks contractions are palpable around the 30th week. Answer 4 is wrong because Goodell's, Hegar's, and Chadwick's signs are first noted at 6-8 weeks of pregnancy, and this fundal height is consistent with the 16th week of gestation The best answer is derived from the correct time-frame—(1) and (2) occur later than 20 weeks; (4) occurs earlier. A new mother tells the nurse she is planning to breastfeed her son until he is 2 years old so she won't have to worry about getting pregnant. Which response demonstrates appropriate health teaching? Lactation does suppress ovulation, so you'll be pretty safe. You are safe only as long as you don't menstruate. It's best to use some other form of birth control. You may not menstruate, hut you may ovulate and could get pregnant. You'll find you won't be interested in intercourse until you wean your baby. Although lactation does suppress ovulation, time of ovulation varies widely, making this an unreliable birth control method (bottle-feeding mothers have ovulated as early as 36 days postpartum; breastfeeding mothers, as early as 39 days postpartum). Answer 1 is incorrect because of unpredictability of the time of inhibition of ovulation. Answer 2 is wrong because the mother may have anovulatory or ovulatory menses or may ovulate in the absence of menstruation. Answer 4 is wrong because the woman may desire to resume intercourse when lochia stops When a question asks which plan is appropriate, identify and eliminate the inappropriate statements first. Nursing assessments during the fourth stage of labor following placenta previa will include close monitoring for signs of hemorrhage. This nursing decision is based on which rationale? Placenta was implanted in lower uterine segment, where there are fewer muscle fibers to contract the placental site. The area under an abrupted placenta never contracts as strongly as when there is no premature separation. Since the placenta was surgically removed, the uterine muscle does not contract as efficiently. The woman lost 250 mL of blood during the third stage of labor. The lower uterine segment does not contract as effectively as the fundus. Postpartum bleeding is more common in women with placenta previa. Answer 2 is incorrect because the woman did not have abruptio placentae. Answer 3 is wrong because surgical removal of the placenta does not inhibit uterine contraction. Answer 4 is wrong because a loss of 250 mL during the third stage is within normal limits The question is asking why hemorrhage may occur with placenta previa. Answers 2 and 4 can be eliminated because they do not answer this question. A woman in labor using the Lamaze technique is examined and found lo be in transition. Which breathing pattern used at this time would indicate a need for nursing intervention? Rapid, shallow chest breathing. Slow, deep, abdominal breathing. Use of intercostal muscles with diaphragm relaxed. Beginning and ending each contraction with two cleansing breaths. is the best answer because intervention is needed. The breathing technique recommended for transition is rapid, shallow chest breathing. Answer 1 is not the choice because rapid, shallow chest breathing is advised. Answer 3 is not the choice because the use of intercostal muscles with a relaxed diaphragm is recommended. Answer 4 is not the choice because each contraction should begin and end with two cleansing breaths in the Lamaze method Look for the inadvisable breathing patterns. Narrow the choice to two contradictory breathing options: rapid and shallow chest vs. slow and deep abdominal. Note also that the question asks for transition phase breathing, not for latent and early active phase, where Answer 2 would be appropriate. Which of these normal physiological changes has greater implications for the woman with a history of rheumatic fever at age 8, and requires more teaching about warning signs and symptoms needing prompt medical evaluation? Increased venous pressure in lower extremities. Placental production of HPL. Increased cardiac output. Relaxation of the cardiac sphincter. Increased cardiac output has greater implications because her heart has been compromised by rheumatic fever She should understand and be able to recognize signs of complications associated with her heart function. Answer 1 is wrong because increased venous pressure in the lower extremities presents little more than an annoyance. Answer 2 is wrong because placental production of HPL presents a greater problem for a woman with diabetes. Answer 4 is wrong because relaxation of the cardiac results in minor complaints Recall that the potential risk of rheumatic fever is cardiac problems. Following an amniotomy, the nurse remains alert for any signs of complications. In addition to the FHR, which of the following may indicate fetal distress? Crowning and increased fetal activity. Crowning and hypotonic contractions. Increased fetal activity and meconium-stained amniotic fluid. Baseline variability on the monitor strip. Significantly increased fetal activity and meconium-stained amniotic fluid are signs of fetal distress. Answer 1 is incorrect because crowning is followed rapidly by birth and because any fetal distress can be treated promptly. Answer 2 is wrong because crowning is shortly followed by birth. Answer 4 is wrong because baseline variability is a normal fetal pattern Choose the abnormal fetal and amniotic fluid signs. A woman in labor insists on remaining in a supine position in bed. Which response should the nurse make regarding this behavior? It's best for the baby if you lie on your side. These two pillows under your knees will be good for the baby and more comfortable for you. You will get nauseated and light-headed if you stay in that position. "This rolled-up towel under your hip will do the job just as well." Tilting the hip moves the heavy uterus off the major blood vessels (the vena cava and aorta), preventing supine hypotension, reduced placental perfusion, and fetal bradycardia. Answer 1 is incorrect because the statement denies the need for comfort at this time. Answer 2 is wrong because the pillows may increase her comfort but will not prevent supine hypotension. Answer 3 is wrong because the statement may be perceived as a threat and does not recognize the woman's need for comfort and emotional support In positioning a patient, decide what you are trying to prevent or promote. Understand the effects of vena caval syndrome and preventive position changes. Which of the following would the nurse note as a deviation from the normal characteristics of the term neonate? Head circumference larger than chest circumference. Diaphragmatic breathing. Passage of meconium stool. Epicanthal folds and simian line. Epicanthal folds and simian lines are associated with a diagnosis of Down syndrome. Answer 1 is incorrect because the head is the largest part of the newborn's body and is larger than the chest. Answer 2 is wrong because diaphragmatic breathing is the normal newborn pattern of respiration. Answer 3 is wrong because passage of meconium stool immediately following birth is within the normal pattern for newborns "Deviation from normal" means look for what is not normal. The reason the nurse keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, he or she requires: Less oxygen, and the newborn's metabolic rate increases. More oxygen, and the newborn's metabolic rate decreases. More oxygen, and the newborn's metabolic rate increases. Less oxygen, and the newborn's metabolic rate decreases. When cold, the infant requires more oxygen and there is an increase in the newborn's metabolic rate. Nonshivering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption; therefore the newborn increases its heat production. Answer 1 is incorrect because more oxygen is needed, not less. Answer 2 is incorrect because the metabolic rate increases, not decreases. Answer 4 is incorrect because both oxygen needs and metabolic rate increase You can eliminate the two options with "less oxygen" first, because of the physiological responses of the newborn to thermoregulation. Recall complications associated with cold stress. A mother is in the third stage of labor. The nurse is observing for signs of separation of the placenta, which include which of the following? The uterus becomes globular. The fundus appears at the introitus. The umbilical cord is shortened. Mucoid discharge is increased. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. Answer 2 is incorrect because the placenta appears at the introitus, not the fundus of the uterus. Answer 3 is incorrect because the umbilical cord lengthens with placental separation, not shortens. Answer 4 is incorrect because there is often an increase in bloody discharge, not mucoid Picture what happens to the shape of uterus as the placenta separates from it. Immediately after a woman's membranes have ruptured, the first priority of nursing care is to: Take the woman's temperature. Time the woman's contractions. Check the fetal heart rate. Check the woman' s blood pressure. Fetal heart rate is of primary concern, because the environment for the fetus has changed. There is an increased risk for prolapse of the umbilical cord immediately after rupture of membranes, especially if the presenting part is not engaged. Answer 1 is incorrect because this is a secondary priority. The woman may develop an elevated temperature later because of increased risk of infection. Answer 2 is incorrect because this is a secondary priority. Answer 4 is incorrect because the woman's blood pressure will probably not change in response to the rupture of her membranes Think heart rate first! Study tip: Review the assessment and nursing interventions for the emergency condition of prolapse of the umbilical cord. A woman in the postpartum stage has a low rubella titer and receives a rubella virus vaccine. Because she is being immunized, which instruction is most important for the nurse to include in health teaching? Have your titers checked in two weeks. Do not eat products that contain eggs for the next twenty-four hours. Do not become pregnant for three months. Expect to have a slight rash in a day or two. Women who receive live rubella virus vaccine should be advised not to become pregnant for 3 months because of the potential risk to the fetus (congenital measles syndrome). Answer 1 is incorrect because immunity is not established fully by 2 weeks. Answer 2 is incorrect because dietary restrictions are not necessary following rubella vaccine. Answer 4 is incorrect because mild symptoms may occur 11-20 days after vaccination, and are usually mild and transient. Breastfeeding is not contraindicated following vaccination. Focus on the two options about what not to do, and choose the one that deals with prevention of risk to the fetus. A nurse's aide reports to the RN that a multigravida who is 6 hours postpartum has not voided and has not ambulated yet. The patient says she has no desire to void and says that with her last infant she needed to be catheterized. The RN should instruct the nurse's aide to: Ask the woman if she is bleeding heavily. Find out how much fluid the woman has consumed in the last 6 hours. Not be concerned because this is normal for this patient. Assist the woman to the bathroom. If a woman has not voided by 6 hours after delivery, she should be encouraged to ambulate to the bathroom, This may assist her in voiding. Catheterization may need to be done, but only after she is given the opportunity to void. Answer 1 is incorrect because she should be encouraged to empty her bladder, and then her fundus should be assessed for firmness and position. Women who have distended bladders, however, may be at risk for uterine atony and increased bleeding. Answer 2 is incorrect because her fluid intake is not likely to have an impact on her ability to void at this point in the postpartum period. Urinary retention is probably caused from birth trauma and effects of anesthesia. Answer 3 is incorrect because a woman should void and empty her bladder within 6 hours postpartum. Women will begin to diurese in the postpartum period, and there is an increased risk of postpartum bleeding and rupture of the bladder Choose the answer that delegates activities to LPN/LVN for stable patients with predictable outcomes, not assessment activities (1,2). A woman had previously used a diaphragm for contraception before her pregnancy. Now at 6 weeks postpartum, she asks the nurse if she needs to have her diaphragm refitted. The best response is: Yes, it should be refitted after a pregnancy. No, it is not necessary. Once involution is completed, it should fit as it did before. It isn't advisable to use a diaphragm after giving birth to a baby. Yes, but you should wait until you are 3 months postpartum. A diaphragm should be refitted after each pregnancy around 6 weeks postpartum. It should also be refitted it the woman loses or gains a significant amount of weight (15-20 lb) or has uterine or vaginal surgery. Answer 2 is incorrect because a pregnancy can change the shape and size of the cervix and vagina. Answer 3 is incorrect because women may use a diaphragm for postpartum contraception once involution is completed. Answer 4 is incorrect because she does not need to wait until 3 months postpartum. Usually 6 weeks is sufficient It is a "yes" answer, but eliminate the option with the specific time frame (i.e., 3 months). The nurse should teach the parents' group that Chlamydiatrachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause: Discoloration of baby and adult teeth. Snuffles and rhagades in the newborn. Pneumonia in the newborn. Central hearing defects in infancy. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia. Answer 1 is incorrect because discolored teeth are caused by tetracycline. Answer 2 is incorrect because snuffles is seen with congenital syphilis. Rhagades refers to circumoral radiating scars that result from cracked, rough mucocutaneous lesions of the lips. Answer 4 is incorrect because congenital rubella causes central and peripheral hearing defects in infancy Eliminate two of the options that are congenital (2, 4), and (1), which is caused by a medication. A 13-year-old girl just delivered an infant who needs emergency surgery. The consent form should be signed by: The mother of the baby. The grandmother of the baby. The RN. The MD. Even though the mother is a minor, she is legally able to sign consent for her own child. Answer 2 is incorrect because the baby's mother is able to give consent. The exception might be if the mother is unable and the baby's grandmother has power of attorney for her daughter. Answer 3 is incorrect because the RN should not sign a consent form for treatment or surgery. Answer 4 is incorrect because the physician cannot sign a consent form for treatment or surgery Eliminate who should not sign the consent form (i.e., all but the patient should not). The nurse manager on a maternity unit is informed that a woman who is 36 weeks pregnant with severe preeclampsia is to be admitted to the unit. Which bed assignment is the best choice? Bed in a double room 50 feet from the nurse's station with a roommate who has rheumatic heart disease. Bed in a double room next to the nurse's station with a roommate who is a drug addict with withdrawal symptoms. Bed in a four-bed unit with all other women who are postpartum. Bed in a four-bed unit with other women who have pyelonephritis, diabetes, and premature rupture of membranes. A quiet room close to the nurse's station provides the best environment for treatment (observation and decreased stimulation). A private room is ideal, but of these choices, Answer 1 is the best. Answers 2,3, and 4 are incorrect because too much noise or stimulation can precipitate eclamptic seizures. All of these environments could be too noisy and too stimulating Because of severe preeclampsia, choose the least stimulating environment (i.e., I noise, 1 number of people). The nurse analyzes the following data: A woman in labor has remained at 6 cm dilation, — 1 station (vertex presentation), with molding of the baby's head at +2 station for 3 hours. he baby's FHR has increased from a baseline of 140 to 170. The physician orders Pitocin augmentation of labor. The nurse's correct action would be to: Add Pitocin to the IV and label it correctly. Start the Pitocin drip using an IV pump. Accurately chart the Pitocin infusion. Refuse to carry out the order for Pitocin augmentation. The data indicate that the woman has an arrest of her labor (potentially cephalopelvic disproportion), and the fetus is developing a tachycardia (fetal distress). It would be contraindicated to augment labor under these circumstances. The nurse should emphasize the assessment findings to the physician. Answers 1,2, and 3 arc incorrect because augmentation of labor is contraindicated with the current situation Because of the risk of hyperstimulation of the uterus, choose the one answer that does not give it. Think of patient safety, and think of the legal responsibility of the RN. When forceps are used for the birth of an infant's head, the newborn should be assessed for: Torticollis. Facial paralysis. Fractured clavicle. Cephalhematoma. Facial paralysis can occur when the forcep blades compress cranial nerve VII (facial) anterior to the ears. It is usually mild and temporary, lasting only a few days. Answer 1 is incorrect. Torticollis, or wry neck, is caused by a shortened sternocleidomastoid muscle on one side of the fetal neck. Answer 3 is incorrect. Fractured clavicle is usually caused when the shoulders are being born, when the infant is large, or when the mother's pelvis is small. Answer 4 is incorrect. Cephalhematoma is not caused by properly placed forceps. This bleeding between the periosteum and one or more of the cranial bones (especially the parietal) is secondary to pressure from the maternal pelvis Choose the one option that is related to nerve damage. Less than 24 hours after being discharged, a new postpartum mother calls the nurse on the mother/baby unit. She reports that she has very heavy, bright-red bleeding. What would be the best advice to give her? Don't worry about it; it is normal. Lie down for about an hour. Check your bleeding then, and if it is still as heavy, call me back. Lie down, massage your uterus (lower abdomen). If it does not firm up and your bleeding does not decrease, come to the hospital immediately. Call your doctor and ask what to do. This is subinvolution of the uterus and may cause postpartum hemorrhage. The uterus should firm up with massage. If it does not, or the bleeding continues to be heavy, she should go to the hospital immediately; she might need oxytocin and perhaps a D&C. She should also be checked for retained tissue, birth canal lacerations, or infection. Answer 1 is incorrect because this is too much bleeding, and a return to bright-red, heavy bleeding postpartum, after the flow has decreased, is not normal. Answer 2 is not correct because the woman could be hemorrhaging. She should not wait an hour for intervention. Answer 4 is incorrect because the nurse's role after early discharge is to triage problems over the phone and prioritize which ones need immediate medical attention Consider time sequence when advising patients (e.g., when is this taking place?). Of the following findings in a full-term newborn, which is not an expected outcome of maternal hormone influence, and therefore should be reported? Witch's milk. Slight vaginal bleeding. Undescended testicles. Linea nigra. Undescended testicles are a condition unrelated to maternal hormonal influence. By 36-38 weeks of gestation, they should be descending through the inguinal canal and into the scrotal sac. Answers 1,2, and 4 are incorrect. They are all a result of maternal hormonal influences and are considered normal findings in the full-term neonate Eliminate the three options that are related to maternal hormone influence. Key concept is time related (i.e., at term, not at 36 weeks of gestation or earlier). The plan of care developed by nurses for parents of a drug-dependent baby includes: Recommendations for minimal contact between parents and the infant. Ways to encourage parent-infant bonding and any positive parental responses to the baby. Discouraging attachment between the parents and baby. Acknowledgment that drug-dependent parents are less likely to be interested in their babies. Positive parent-infant bonding and responses to the baby are encouraged; this may help motivate parents to enter drug rehabilitation. Answer 1 is incorrect. Positive parental contact should be encouraged. Answer 3 is incorrect. Positive parental contact should be encouraged. Answer 4 is incorrect. The nurse cannot assume that drug-dependent parents are less likely to be interested in their babies Choose the option that would reflect the nurse's advocacy role in fostering the well-being of the family. Because Answers 1 and 3 are really saying the same thing, they cannot be correct. Answer 2 is the opposite of the incorrect options (1 and 3). Choose the option that is different from the others. The nurse is to assign a nurse's aide on the postpartum unit to care for patients. The aide has a cold that day, but no other problems. Which patient would the nurse not want to assign to this nurse's aide? Woman in renal failure. Woman who has hypertension. Woman who had a prolonged labor. Woman who has AIDS. The woman with AIDS has compromised immunity. The nurse should not assign this patient to a health care provider who has a viral or infectious illness. Answers 1, 2, and 3 are incorrect. It would not be as great a risk for patients with renal failure, hypertension, or a prolonged labor to have contact with a health care provider who has a cold Test-taking tip Consider the nurse's role in delegation of care, and think about patient safety as the priority when there is a risk of exposure to infectious or viral agents for patients with compromised immunity. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature: Is the average temperature taken each morning. Should be recorded each morning before any activity. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test. Can be done with a mercury thermometer but not a digital one. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2CC to 36.3°C during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature (approximately 0.05°C) may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2°-0./loC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred. Answer 1 is incorrect. The BBT is not an average temperature, but must be taken every day to assess for slight fluctuations. Answer 3 is incorrect. Cervical mucus assessment is only one of the signs of approaching ovulation. Many things, such as semen, contraceptive gels, vaginal discharge from infection, and sexual arousal, can affect the amount and consistency of cervical mucus. Other factors, such as illness, can affect the BBT as well. Answer 4 is incorrect. Either a mercury or digital thermometer may be used to accurately measure BBT; it is advisable that a woman uses the same thermometer the entire month, however, because the readings might vary slightly The key is when (i.e., each morning before activity). A teaching plan to use in presenting information to parents about fetal development should include the fact that the embryonic membrane closest to the uterine lining, and the first to form, is called the. Amnion. Amniotic sac. Chorion. Mesoderm. At the time of implantation, two fetal membranes, which will surround the developing embryo, begin to form. The chorion develops from the trophoblast and contains chorionic villi on its surface. The villi burrowing into the deciduas increase in size and complexity as the vascular processes develop into the placenta. The villi eventually atrophy and degenerate, leaving a smooth chorionic membrane. Answer 1 is incorrect because the amnion is the other embryonic membrane, the inner cell membrane that develops from the interior cells of the blastocyst. The amnion eventually becomes the covering of the umbilical cord and covers the chorion on the fetal surface of the placenta. Answer 2 is incorrect because the amniotic sac is the fluid-filled sac inside the membranes surrounding the embryo/fetus. Answer 4 is incorrect because the mesoderm is a primary germ layer that develops into fetal bones, teeth, and muscles The correct answer is based on knowing when the development of the embryo, including membranes, amniotic sac, and fluid, occurs. The amniotic fluid cushions the embryo/fetus against mechanical injury, controls the embryo/fetus' temperature, and: Creates adherence of the amnion. Provides for fetal respiration and metabolism. Provides a means of nutrient exchange for the embryo/fetus. Allows freedom of movement so the embryo/fetus can change position. Amniotic fluid allows freedom of movement for musculoskeletal development of the fetus, in addition to the other functions mentioned. Answer 1 is incorrect because the amnion and chorion are formed and adhered before the development of the fluid. Answer 2 is incorrect because the placenta provides for oxygen and carbon dioxide exchange. Answer 3 is incorrect because one of the metabolic functions of the placenta is nutrient exchange Visualize the fetus moving around in the fluid. Eliminate the two options that are functions of the placenta. During a prenatal exam a patient asks the nurse, "How does my baby breathe inside?" The nurse's best response is: "The lungs of the fetus carry out respiratory gas exchange in utero." The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream. The blood from the placenta is carried through the umbilical artery, which penetrates the abdominal wall of the fetus. The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy. Oxygen diffuses from the maternal blood across the placental membranes into the fetal blood, and carbon dioxide diffuses in the opposite direction. In this way, the placenta functions as lungs for the fetus. Answer 1 is incorrect because respiratory gas exchange does not occur in the fetal lung while in utero. Answer 3 is incorrect because blood from the placenta is carried through the umbilical vein, not artery, to the fetus. Answer 4 is incorrect because it is not the mother's hemoglobin that assists the baby to breathe; the placenta functions as the fetal lungs until birth Remember—placenta = fetal "lungs." The hematocrit decreases an average of 7-10% during pregnancy. This is referred to as physiologic anemia of pregnancy. Which mechanism best explains this decrease? The total erythrocyte count increases about 30%; the plasma volume increases about 50%. The total erythrocyte count increases about 50%; the plasma volume decreases 30%. The total erythrocyte count decreases 30%; the plasma volume increases about 50%. The erythrocyte count remains the same; the plasma volume increases 50%. Both red blood cells (RBCs) and plasma increase in pregnancy; but because the plasma increase exceeds the increase in RBC production, there is a decrease in both Hct and Hgb due to hemodilution. Answers 2, 3, and 4 are incorrect because the increases are not correct. Neither erythrocyte nor plasma volume decreases during pregnancy The increases in both are a protective mechanism for both mother and fetus. Assessment data indicate an abnormality at 20 weeks of gestation when: The fundal height measurement is at 4 fingers below the umbilicus. Fetal movements are felt faintly on the right side of the abdomen. The woman complains of backache and fatigue. The fetal heart rate is 140 and sometimes is difficult to count. The height of the fundus (single pregnancy) should measure about 20 cm at 20 weeks (at the umbilicus). A measurement less than that might indicate inadequate fetal growth or an error in calculation of gestational age. Answers 2,3 and 4 are all findings that would be considered normal during the second trimester of pregnancy The key point is when that is, when prenatal assessment findings are not normal during the second trimester. During the postpartum period, the nurse should advise the breastfeeding adult woman to: Increase her calories by about 600 kcal/day over her pregnancy requirements. Return to prepregnancy requirements for protein. Increase her calories by about 500 kcal/day over her prepregnancy requirements. Decrease the amount of calcium that was consumed during pregnancy. The suggested RDA is an increase of 500 kcal more than the adult woman's nonpregnant intake. It is recommended that lactating women consume at least 1800 kcal/day because it becomes difficult to obtain adequate nutrients for the maintenance of lactation at levels below that. Answer 1 is incorrect because this exceeds kcal requirements. It is recommended to increase 300 kcal/day for pregnancy and an additional 200 kcal/day (total 500 kcal) during lactation. Answer 2 is incorrect because protein requirements increase in both pregnancy and lactation. RDA for magnesium, vitamin C, zinc, and protein is slightly to moderately higher than during pregnancy. Answer 4 is incorrect because it is especially important that the calcium intake be adequate during pregnancy and lactation First, decide if the RDA in the correct answer relates to nonpregnancy time period or during pregnancy. Next, you can eliminate Answers 1 and 4 because they relate to the time during pregnancy. Select Answer 3 rather than (2) because of need to increase calories. Remember: T calories, T protein over prepregnancy requirements. When responding to a question from a new mother about producing enough milk for the baby as the baby grows and needs more milk at each feeding, the nurse should explain that: The mother's milk supply will increase as the infant demands more at each feeding. The breast milk will gradually become richer to supply additional calories. Early addition of solid baby foods will ensure an infant's nutritional needs. As the infant requires more milk, feedings should be supplemented with cow's milk. As milk is removed from the breast, more is produced. Answers 2,3, and 4 are incorrect because as the infant requires more milk with each feeding, the woman's breasts will meet the demands with adequate nutrition and volume if there is adequate maternal nutrition and hydration. Also, early introduction of solids (Answer 3) may make the infant more prone to food allergies. Regular feeding of solids may also lead to decreased intake of breast milk and has been associated with early cessation of breastfeeding -Remember the concept that milk production during lactation is a supply-demand system. Which woman would be at highest risk for preterm labor? The pregnant woman who is working full-time at a sedentary job. The woman who is pregnant with twins. The woman who has gained 35 lb by 36 weeks of gestation. The woman who is pregnant with her first baby. The considerable uterine distention involved with multiple gestation can place the woman at risk for premature contractions, cervical dilation, and delivery. If there are risk factors for preterm birth, abstinence from orgasm, nipple stimulation, and increased rest during the last trimester maybe recommended to avoid preterm labor. Answers 1,3, and 4 do not necessarily place a woman at increased risk for preterm labor. Inadequate weight gain is a risk factor, not extra weight gain. A history of preterm labor must always be considered a high-risk factor Visualize what happens to the uterus with twins and what that can lead to. A woman gave birth to her second daughter. She tells the nurse, "I'm concerned my two-year-old daughter will not accept the new baby." The nurse should suggest that: The older daughter not have much interaction with the baby at the hospital, because she may harm her new sibling. The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home. The older daughter be given more responsibility and assure her "that she is a big girl now, and doesn't need Mommy as much." The woman spend time alone with her older daughter when the baby is sleeping. The introduction of a baby into a family with one or more children challenges parents to promote acceptance of the baby by siblings. The parents' attitudes toward the arrival of the baby can set the stage for the other children's reactions. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy. Answer 1 is incorrect because direct sibling contact does not place healthy newborns at risk for exposure to pathogenic organisms or for physical harm from siblings. It may facilitate the adjustment to the addition of a new family member. Answer 2 is incorrect because parents need to assume the task of caring for a new child while not neglecting the others. A temporary separation might be necessary while the mother recovers, but involvement of the whole family is important. Answer 3 is incorrect because the older child's goal is to maintain the lead position in a family. If the parents threaten that position even more by changing that child's status, it may delay adjustment to the new sibling. Allowing the older child to help with the new baby is positive It is about the mother and 2-year-old first. Focus on the age-appropriate answer about reducing sibling rivalry. The best position for the delivery room nurse to place a newborn with myelomeningocele at the lumbosacral area in is: Prone. Supine. Side-lying. Trendelenburg. Place the infant with a myelomeningocele on her stomach in a prone position to avoid pressure on the sac, which could cause tears, leaks, and infection. The side-lying position (Answer 3) might be an acceptable second choice, depending on the exact size and location of the sac placing the infant on her back (Answer 2) is absolutely contraindicated, because this would lead to immediate rupture of the sac. Trendelenburg position (Answer 4) is unnecessary for this infant. Picture the anatomy where the problem is and avoid on the back positions (2, 4) A school-age child with rheumatic fever complains of severe joint pains in the knees and ankles. The best method to pro vide relief would be for the nurse to: Give a warm bath or shower. Apply splints to the affected joints. Refer the child to physical therapy. Place a bed cradle over the child's legs. For a child experiencing migratory polyarthritis secondary to rheumatic fever, even the weight of a single sheet can cause excruciating pain; therefore, a bed cradle will help keep the linens off the child's joints and provide symptomatic relief. This child is most likely on bed rest, thus making a bath or shower (Answer 1) out of the question. Splints or a referral to physical therapy (Answers 2, 3) is unnecessary, because this type of arthritis causes no permanent deformities. Comfort is the priority of care, because of pain associated with migratory polyarthritis A hospitalized school-age child is very quiet and seldom talks to the staff. The nurse can best communicate with this child by saying: I've noticed you seem very quiet. Is anything troubling you? Let's tell each other a secret; you start by telling me what you are thinking. It must be awfully hard to be away from home. Let's call your mom! Draw me some pictures of the things you've seen and done while you've been in the hospital. Projective techniques seem to work best with school-age children in getting them to share their thoughts, feelings, and experiences. Direct questioning (Answer 1) often proves too threatening, causing the child to become even quieter. Challenging the child directly to "tell secrets" (Answer 2) is also too threatening and will likely cause the child to refuse to speak about anything. Calling the child's mother (Answer 3) will not necessarily assist the child to communicate with the nurse. Select the age-appropriate, nonthreatening approach. When in doubt, note the pattern in responses: three arc verbal and one is nonverbal (draw). Choose the method that is different. Three of the following signs or symptoms indicate an improvement in the condition of a toddler with laryngotracheobronchitis. Which one indicates a worsening and should be promptly reported to the physician? Apical pulse = 118. Increase in appetite. Progressive hoarseness. Pink nailbeds. Progressive hoarseness, followed by aphonia, is an ominous sign of impending airway obstruction and respiratory arrest secondary to edema and inflammation. This must be promptly reported to the physician, who will probably do an emergency tracheostomy AN apical pulse of 118 (Answer 1) is normal for a toddler; pink nailbeds (Answer 4) indicate a satisfactory level of oxygenation AS the toddler begins to improve, appetite should also pick up (Answer 2). The question calls for an option that is not normal (not OK) and possibly life threatening The nurse reviews a toddler's immunizations with the parents and finds that the child has had all immunizations recommended during the toddler years. The nurse should advise the parents that, at 4 to 6 years of age, the child should next receive: MMR (measles, mumps, rubella) and hepatitis B. Hepatitis B and varicella. Haemophilus influenzae type b and DTP. MMR (measles, mumps, rubella), polio, and DTP. At preschool age (4-6 years), the child should receive immunizations for DTP, OPV, and MMR. MMR (Answer 1) is correct, but hepatitis D is not. I hepatitis (Answer 2) is completed by 18 months, as is varicella. Haemophilus influenzae (Answer 3) is completed by 15 months, although DTP is correct. The best answer is based on knowing the recommended schedule of immunizations Which is the most common complaint by parents about infants with heart disease? Frequent, severe respiratory infections. Slower development. Stunted growth. Difficult to feed. Typically, the majority of parents of infants with CHD complain about the infant's being very difficult to feed: must be awakened to feed, has a weak suck, may turn blue with feeding, takes an overly long time to feed but falls asleep before finishing. Because of the weak suck and altered cardiopulmonary dynamics, the infant is also prone to aspiration, pneumonia, and various respiratory infections (Answer 1) as well, although parents often do not make the connection between these factors. In addition, because of the difficulty in feeding the infant, the infant typically has developmental delays (Answer 2) and a slow rate of growth (Answer 3), although again this is not what the majority of parents of infants with CHD complain about. Because all answers are correct and interrelated, the clue is in the stem. The parents are most likely to have a daily problem with feeding The nurse in the newborn nursery should plan any interventions with a newborn with myelomeningocele based on the knowledge that the major short-term complication the child is most likely to suffer is: Hydrocephalus. Meningitis. Mental retardation. Paraplegia. The major short-term complication that infants with myelomeningocele face is infection following a tear or rupture of the sac. Hydrocephalus (Answer 1) does occur in 90% of these cases, usually following closure of the sac, but it is thought to be part of the CNS defect rather than a complication. Likewise, paraplegia (Answer 4) is part of the symptom complex these patients have, rather than a complication. Mental retardation (Answer 3) may or may not occur, but if it does occur it is a long-term complication. The question asks for a short-term complication rather than part of the symptoms (one that will be evident within 1-2 wk) The physician orders Tylenol elixir for a 14-month-old with a fever of 102°F. Considering this child's developmental level and diagnosis, which would be the best approach by the nurse? Use the medicine cup and tell the child the "pretty red syrup" will taste sweet like candy. Mix the medication with 4 oz of apple juice and allow the child to drink it through a "crazy straw." Put the medication into a brightly colored plastic cup and give the child a chance to drink it. Raise the child to a sitting position, bring the medicine cup to the lips, and tell the child kindly but firmly to drink it. As a toddler, this child will probably assert autonomy by refusing to take this medication. The best approach is to be firm yet kind, and always calm. No child should be told that medicine is like candy (Answer 1). Medication should be mixed with no more than 1 teaspoon of any nonessential food or beverage (Answer 2). This toddler will probably not drink this medication (Answer 3), and the nurse should not offer this choice because, if the child refuses, a "power struggle" will follow. Look for the choice that addresses the major developmental task for toddler—autonomy A toddler is to be placed in a croupette. The nurse should plan to perform which nursing action? Remove all toys from the crib. Withhold all liquids and solids temporarily. Monitor oxygen concentration daily and record in notes. Evaluate the toddler's reaction to oxygen therapy in terms of vital signs and color. If the toddler responds well to oxygen therapy, the child should show clinical improvement in terms of pink lips and nailbeds and normal vital signs, especially pulse. "All" toys do not have to be removed from the crib (Answer 1), nor will the child have to be NPO (Answer 2), although the child will probably be somewhat anorexic and prefer clear, cool liquids initially. Oxygen concentrations should be monitored and recorded at least every 2 hours (Answer 3). Eliminate the two options with the absolute "all." Also, recall that in the nursing process, nursing interventions are followed by evaluation The nurse should review principles of care with a 12-year-old child with asthma. Which comment by the child would require additional teaching by the nurse? I keep all my stuffed animals on my bookcase now. I have vinyl miniblinds on the windows in my room. I gave my cat to my best friend. I joined the swim team at school. Children with asthma should have no stuffed animals in their rooms, because they tend to collect dust; therefore more teaching would be needed. Additional measures to "allergy proof" the room and home should include using only washable miniblinds rather than curtains (Answer 2) and having no pets in the home (Answer 3). Moderate exercise such as swimming (Answer 4) is recommended. The question is asking for the incorrect response A mother asks the nurse about the normal time for the onset of menstruation. The nurse would be most correct in advising her that menses usually begin at age: 11.2 years 12 years. 12.8 years. 13.5 years. The average age for the onset of menstruation for American girls is 12.8 years of age; girls between 10.5 and 15 years can begin to menstruate within the normal range (Answers1,2,4). "Normal," "usually," and "average" are used as synonyms here. Know age-typical prepubertal and pubertal developmental norms In doing an infant's admission examination, the nurse notes all the following abnormal findings. Which one is the most common sign of heart disease the nurse should assess? Circumoral cyanosis. Hypertension. Diastolic murmur. Tachycardia. The majority of infants with CHD have tachycardia, or a heart rate above 160 beats/min; this is often the first sign of CHD that the nurse can assess. Circumoral cyanosis (Answer 1), hypertension (Answer 2), and diastolic murmur (Answer 3) all may or may not be present, depending on the type and severity of the defect. Note the use of the words "most common sign" in this question. Eliminate the three others that may not be present To "flood" the croupette with oxygen before placing a toddler in the tent, the nurse should initially adjust the oxygen flow rate to: 2-3 L/min. 4-5 L/min. 8-10 L/min. 15 L/min. To "flood" the croupette with oxygen means to raise the oxygen concentration to that level ordered by the physician; in general, the flow rate should be adjusted to 15 L/min, the tent should be closed and tucked in, and the nurse should wait about 15 minutes before checking the concentration and readjusting the flow. Lower flow rates (Answers 1, 2, 3) would result in lower-than-required oxygen concentrations. Note the use of the words "initially adjust" in this question A toddler is admitted to the hospital with acute bilateral otitis media, with a temperature of 103°F and tremors in arms and legs. In addition to a spinal tap to rule out bacterial meningitis, the doctor orders all the following. Which order should the nurse perform first? Respiratory isolation. IV 5 dextrose in 0.45 normal saline solution at 35 mL/hr. Tylenol 120mgPOq4h. In caring for a patient with a potentially contagious condition such as meningitis, the first priority is protecting the nurse and other patients by observing appropriate infection control measures, in this case, respiratory isolation. All other nursing care measures would then follow in the appropriate order (Answers 2, 3, 4). Infection control is always a priority of care The doctor orders an IV to infuse at 35 mL/hr; a pediatric microdrip chamber is hanging. How many drops per minute should the nurse regulate the IV to infuse? 5-6. 7-8. 9-10. 35 With a pediatric microdrip chamber, the number of mL/hr = number of drops/min. Therefore, if the physician orders 35 mL/hr, the IV should infuse at 35 drops/min any other flow rate would be incorrect (Answers 1, 2, 3). The nurse must know how to calculate the rate of flow of IVs A 7-year-old who has had leukemia for 2 years was in primary remission for 18 months but recently experienced infections, epistaxis, and abdominal petechiae. The doctor suspects the child is no longer in remission and must be admitted to the hospital. In reviewing admitting blood work, the nurse notes all the following. Which finding should the nurse interpret as the probable cause of the infections? Anemia. Leukopenia. Neutropenia. Thrombocytopenia. Neutropenia is an abnormal decrease in the number of neutrophils, the specific type of WBC responsible for phagocytosis and bacterial destruction; as such, the infection in a patient with leukemia is most commonly related to neutropenia. These patients may also suffer from anemia (Answer 1), leukopenia (Answer 2), or thrombocytopenia (Answer 4), although these blood dyscrasias will result in other signs or symptoms of leukemia. Look for the cause that is directly related A school-age child with rheumatic fever develops heart failure and is placed on digoxin, Lasix, and potassium. The chief purpose for giving potassium is to: Enhance the cardiogenic effect of digoxin. Potentiate the diuretic action of Lasix. Prevent hypokalemia. Pharmacologically induce hyperkalemia. Patients receiving digoxin in addition to Lasix are particularly prone to developing hypokalemia, which can result in digoxin toxicity and potentially fatal cardiac dysrhythmias. Potassium supplements are frequently administered to avoid this problem rather than for any of the other reasons cited here (Answers 1,2,4). It logically follows that if K' is given, the purpose is to replace KH and therefore to avoid low K* Two hospitalized school-age children complain that they are "bored." The nurse should offer them: A game of Monopoly or Life. Workbooks, paper, and pencils. Some books from the hospital library. A chance to stay up late and watch TV. School-age children are notoriously competitive, and they particularly enjoy the challenge of board games such as Monopoly or Life. Although schoolwork is important and should receive due consideration (Answer 2), it will not relieve their boredom. Likewise, books and TV (Answers 3, 4) are less effective diversions for the school-age child. Three options are passive, one is interactive. Remember that school-age children are highly competitive, enjoying interactive games with others A 12-year-old is admitted to the hospital in status asthmaticus, for the second time. In planning care for this child, the nurse must first assess: What she knows about asthma. How she usually cares for herself. What she knows about hospitalization. How she feels about becoming a teenager. In working with children in hospitals, the most important factor for the nurse to assess first is the child's experience with illness and hospitalization. This is of special importance with this child, who has been hospitalized previously. After this most important factor, the nurse would continue the admitting assessment by determining what she knows about asthma (Answer 1), how she usually cares for herself (Answer 2), and how she feels about becoming a teenager (Answer 4). A major principle of teaching-learning is to start where the client is When the nurse begins teaching a teenager with diabetes about insulin, which one fact should be stressed to this teen and the family? Properly controlled dietary management, along with hypoglycemic agents, may eventually be used. Exogenous insulin will be necessary for the rest of the child's life. Activity level, nutritional intake, and state of health will necessitate daily modifications in the insulin dose. Due to the need for insulin, the child should no longer participate in active sports. Because the beta cells of the islets of Langerhans of the pancreas will never again produce a sufficient quantity of insulin, this teenager will remain dependent on insulin injections (exogenous insulin) for the rest of his life. Patients with type 1 diabetes can never rely on hypoglycemic agents to control diabetes (Answer 1), because these drugs work by stimulating the pancreas, and in this case the stimulation would have absolutely no effect. Daily modifications would generally not be necessary (Answer 3), although periodic adjustments in insulin dosage would be needed as this teenager grows. The child can continue to participate in sports (Answer 4), but should be taught to take some extra foods on those days when actively participating in sports. To pick the most theoretically correct answer, pull apart the key points about a time element: eventually, for life, daily, never In doing a child's admission history, the nurse notes all the following signs of hemophilia. The hallmark, or classic sign, of hemophilia is: Excessive hematoma formation. Hemarthrosis. Prolonged bleeding from lacerations. Intracranial bleeding. Hemarthrosis, or bleeding into a joint either spontaneously or following an injury, is considered the hallmark, or most typical sign, of hemophilia. If hemarthrosis is not treated properly or adequately, permanent joint deformities may result. Other signs of hemophilia include prolonged bleeding from a relatively minor injury (Answer 3), excessive or unusual hematoma formation (Answer 1), and intracranial bleeding following a closed head injury (Answer 4). When all are correct, choose the one most associated with pain (a classic symptom of hemophilia), such as pain due to bleeding into a joint The nurse performs a Denver Developmental Screening Test (DDST) on a 3-year-old. Which behavior should the nurse expect this child to be capable of doing? Going up stairs on alternate feet. Pedaling a bicycle. Dressing without supervision, Tying shoelaces. Three-year-olds should be able to coordinate the brain and gross motor activity necessary to go up stairs using alternate feet. They should also be able to pedal a Big Wheel or a tricycle but not a bicycle (Answer 2). Three-year-olds should also be able to get dressed with supervision but not without it (Answer 3). They should not be ready to master tying shoelaces (Answer 4) for another year or two. Remember, three years = three wheels; a 3-year-old should be capable of pedaling a tricycle While admitting an infant, the nurse notes all the following abnormal findings. Which one is considered the classic sign of Hirschsprung's disease? Abdominal distention. Anorexia. Constipation. Vomitus flecked with feces. The classic sign of Hirschsprung's disease is obstinate constipation that persists despite all efforts at treatment. Other symptoms may also occur but are not generally considered specific to Hirschsprung's disease as much as they indicate in Testinal obstruction: abdominal distention (Answer 1), anorexia (Answer 2), and vomiting (Answer 4). Note the use of the words "classic sign" in this question, meaning specific to the condition The best way for a nurse to perform a test on a 9-month-old is to: Take the infant from the mother and ask her to wait in the child's room. Take the infant from the mother and ask her to come with them to the testing area. Briefly talk first with the mother, then take the infant to the testing area alone. Ask the infant's mother to carry the child to the testing area. The instruction manual of the DDST clearly states that the parent should accompany the child who is to have the DDST and that the examiner should do everything possible to establish rapport with the parent and the child. With a 9- month-old, this should include allowing the parent to hold the child rather than separating them for the purpose of Testing (Answers 1, 2, 3). Fear of strangers peaks at 8-9 months of age (i.e., keep the mother and baby together). Therefore, eliminate Answers 1, 3, and 4 For an infant with severe chronic CHF, the formula the nurse should plan to offer would be: Isomil. Lofenalac. Lonalac. Similac 27 with iron. An infant with severe chronic CHF should be on a low-sodium formula, Lonalac. Isomil (Answer 1) is a lactose-free formula that contains a normal amount of sodium. Lofenalac (Answer 2) is the formula used to treat infants with PKU and also contains a normal amount of sodium. Similac 27 with iron (Answer 4) is most frequently used for preterm infants and also contains a normal amount of sodium. Look at the name of the formula and try to think it through; lo = low, na = sodium, lac = sounds like similac. Thus, a low-sodium formula! The parents of a school-age child with leukemia tell the nurse that their daughter frequently has nightmares, and they wonder how to handle this. The nurse would be most correct in advising them to: Comfort her, but leave her in her own bed. Comfort her by bringing her into their bed. Consult a child psychologist to determine why she has recurring sleep disturbances. Encourage the child to keep a written record of her dreams and discuss them with her primary nurse during hospitalization. Most psychologists would recommend that a child be offered comfort in the form of a hug, kiss, or cuddle; however, the child should be left in his or her own bed to avoid overdependence on the parents or possible psychosexual conflicts caused by entering the parents' bed (Answer 2). For the school-age child, nightmares are a common occurrence and can be accepted as a normal part of 3; therefore, no professional intervention is necessary at this time (Answer 3). It could be very difficult for this child to keep written records of her dreams (Answer 4); in fact, such an expectation might lead to even more severe sleep disturbances for her. Focus on two options with "comfort," which are better than "consult" or "written record." As a general rule, children should sleep in their own beds, not with parents Before giving a child digoxin, which pulse would the nurse be most correct in assessing? Apical. Brachial. Pedal. Radial. Before administering digoxin to a child, the nurse should auscultate the apical pulse for a full minute to most accurately evaluate cardiac rate and rhythm. Other pulse sites (Answers 2, 3, 4) are less accurate in children. In this case, the key words "most correct" mean most accurate. Infants' and childrens' pulses should always be checked apically A 20-monfh-old is admitted to the pediatrics unit for the third and final, surgical procedure to correct his congenital hypospadias. When admitting this toddler to the hospital, the nurse should assess all of the following. Which information will be the most important to the nursing plan of care for this toddler? His developmental level. The parents' knowledge level regarding hypospadias, His previous experience with illness and hospitalization. The parents' plans for rooming-in. In working with children in hospitals, the most important factor for the nurse to assess first is what that child's experience with illness and hospitalization has been thus far. This is of special importance with this child, who has previously had two hospitalizations and surgeries; the nurse needs to know if these were positive experiences for this child and how he was able to cope with them. After this, the nurse would continue the admitting assessment by determining the child's developmental level (Answer 1), what the parents already know about hypospadias (Answer 2), and whether the child's parents plan to room-in with him (Answer 4). An important principle of teaching-learning is to always start with what the client already knows A hospitalized preschooler wakes up crying at 2 A.M. and says, "T want my mommy now." The nurse should: Pick the child up and rock the child for a little while. Talk softly to the child while rubbing the back, but leave the child in the crib. Gently but firmly tell the child to go back to sleep. Call the mother and ask her to come to the hospital. Hospitalized preschoolers often regress in their behavior and want "mommy," but this is obviously not practical all the time. The nurse should try to soothe the child back to sleep during the middle of the night. Calling the mother to come right in (Answer 4) would be inappropriate, because the family should not be called in the absence of a genuine emergency. The nurse should also not pick the child up (Answer 1), because hospitalized preschoolers frequently reject everyone except their "mommy." Simply insisting the child go back to sleep (Answer 3) is not enough, because the child needs some degree of comfort at this time. Look at the verbs: "pick ... rock," "talk softly... rubbing back," "firmly tell," "call... mother." Preschoolers will regress when stressed, and respond well to verbal and physical comfort ("talk softly. . . rubbing back.") The nurse does discharge teaching with the mother of a preschooler with epiglottitis before discharge. Which statement by the mother indicates that she has correctly understood the nurse's teaching? I'm so glad that my child is all better now. I will keep my child home from preschool for the rest of this month. I'm still worried that my child will get sick again when we get home. I will get a portable tank of oxygen for my child before he comes home. Although the abrupt onset and critical nature of this illness is very frightening for parents, the child is expected to make a total recovery before discharge. The parents should be aware of this very positive diagnosis. Although discharge instructions from the physician may include some rest at home, there is no need for the child to miss almost a month of school (Answer 2). The parents should not worry about the child's getting sick again (Answer 3) or having oxygen in the home again (Answer 4); the excellent prognosis should be stressed. Eliminate the incorrect statement first. Note the use of the words "correctly understood" in this question After flooding a croupette for 5 minutes, the nurse should readjust the flow rate of oxygen. To maintain an oxygen con centration of 35-40 , the nurse should now adjust the oxygen flow rate to: 2-3 L/min. 4-5 L/min. 8-10 L/min. To maintain an oxygen concentration of 35-40%, the flow rate should now be adjusted to 8-10 L/min; this is the usual concentration ordered for a croup tent. Other flow rates would result in higher or lower concentrations (Answers 1, 2, 4). There is only one theoretically correct answer. Although respiratory therapy often sets up croupettes and other forms of oxygen therapy, the nurse should be thoroughly familiar with the usual rate of flow. In this case, pick the midrange response (not 2-5 or 15) A toddler tries to pull the IV out, and the nurse determines that the child must be restrained to maintain the IV site. Which restraint would the nurse be most correct in applying? Posey jacket. Elbow. Mummy. Clove-hitch. To restrain a toddler receiving IV therapy, clove-hitch restraint to two or more limbs is most effective in maintaining the IV site. A posey jacket (Answer 1) would allow the toddler use of hands with which to pull at the IV. Elbow restraints (Answer 2) would still allow the toddler to stand and twist at the IV tubing. A mummy restraint (Answer 3) would be unnecessarily restrictive for a toddler. Choose the option that is effective while not restraining, by visualizing what these various restraints do and where they are placed A lumbar puncture is performed on a child by the doctor. After the procedure, the nurse should position the child: Flat in bed, with no pillow. Flat in bed, with a small pillow. In semi-Fowler's position. Semiprone, with head to the side. The best position for patients who have had a spinal tap is perfectly flat in bed, with no pillow at all. Such patients are prone to headaches due to the loss of CSF during the spinal tap; until the fluid is naturally replaced by the body, a flat position will minimize cerebral irritation and minimize headache; thus, (Answer 2) is incorrect. Elevating the HOB (Answer 3) will increase headache and is not recommended. There is no need to place the child semiprone (Answer 4) at this time. Focus on two options that are "flat." "Flat" is "flat," meaning no pillow. Following a spinal tap, all patients should be flat in bed When the parents of a newborn with myelomeningocele visit the nursery for the first time, they make no comments about the baby's spinal sac. Instead, they offer many positive observations about size, color, hair, and appearance. The nurse would be most correct in interpreting the parents' behavior as: Attachment. Denial. Immaturity. Love. The usual response to the birth of a defective infant is denial, often manifest in the parents' "refusing" to acknowledge the problem; this is a normal response, at least initially. The parents' comments about their infant, in view of this serious defect, should not be interpreted as attachment (Answer 1), immaturity (Answer 3), or love (Answer 4). Denying (in this case, the obvious physical problem) is one of the most commonly seen defense mechanisms The pediatrician orders syrup of ipecac for a toddler who has ingested a harmful substance. Generally, the nurse should administer this medication only if the child is: Alert and reactive. Convulsing. Comatose. Known to have swallowed a corrosive substance. With a child who has suffered an ingestion, vomiting should be induced only if the child is fully alert and reactive. If the child has any alterations in level of consciousness, such as seizures (Answer 2) or coma (Answer 3), vomiting may cause an aspiration pneumonia. Further, if the child has swallowed a corrosive substance (Answer 4), the substance that burned once going down will burn a second time coming up if vomiting is induced. In this case, when one option (1) is different than two others (2 and 3 = not alert), choose the one that is different; note the use of the words "should administer," implying that you can eliminate three contraindicated situations (2, 3, 4) The mother of a toddler who will have his third, and final, surgical procedure to correct congenital hypospadias questions the need for another surgical procedure while he is still so young. The nurse should stress that: It is the mother's right to refuse surgery at any time. It is in her son's best interest to follow the doctor's recommendations. He can have this third, and final, surgery any time before the onset of puberty. This type of surgery is usually timed to take place between 6 and 18 months of age. The corrective surgery for hypospadias is usually timed to be completed before the child develops body image and castration anxiety, by 18 months of age. Developmental and psychological factors thus play a crucial role in the timing of this surgery, and other explanations (Answers 1, 2, 3) are either incorrect or inappropriate for this child. Note the two options with "time" (3, 4). Select the option that is age specific, not "anytime" (3) After the nurse completes preoperative teaching with a preschooler, which would be the best method for evaluating the effectiveness of the teaching? Ask him to draw a picture of what he will look like after surgery. Using puppets, ask him to show the nurse what he has learned about his surgery. Tell him that this is a test and he must repeat what he has learned about his operation. Suggest his parents check on their child's level of understanding and report back to the nurse. When doing preoperative teaching with preschoolers, the best method is to use puppets (doctor, nurse, hospital setup) to "act out" what the child can expect to happen. For evaluating the teaching, the nurse can then ask the child to use puppets to give a return demonstration of what was learned; this enables the nurse to clarify any misconceptions or answer any lingering questions the child might still have. Most preschoolers will not be able to accurately draw pictures regarding the factual information of preoperative teaching (Answer 1), although this might be a good way to get at feelings about the surgery or hospital. A preschooler probably has had limited experience with " Tests" (Answer 3). The nurse should not rely on the parents to evaluate the pre operative teaching (Answer 4), because they are not professionals and are most likely too involved emotionally. Preschoolers respond best to play— therapeutic, or medical The nurse should withhold a 6 year-old's digoxin and notify the physician if the child's pulse was below: 80 beats/min. 90 beats/min. 100 beats/min. 110 beats/min. The lower limit of a normal pulse rate for a 6-year-old is 75-80 beats/min; the nurse would be most correct in with holding the child's digoxin and notifying the physician if the pulse were below 80. A pulse rate of from 90 to 110 (Answers 2, 3, 4) would be considered within normal limits for a 6-year-old, and the nurse would be correct in administering the medication as ordered. The nurse should know approximate pulse rate norms for children of varying age groups. Key word is withhold with age-relevant norm for bradycardia An adolescent is admitted to the hospital in sickle cell crisis with severe pain in the legs and abdomen. The adolescent asks the nurse why the doctor ordered oxygen when there is no trouble breathing. The nurse would be most correct in stating that the main therapeutic effect of oxygen is to: Reverse sickling of RBCs. Prevent further sickling. Prevent respiratory complications. Increase the oxygen-carrying capacity of RBCs. Sickling of RBCs occurs under conditions of low oxygen tension; giving this adolescent oxygen will prevent further sickling of RBCs, but it will not reverse the sickling of cells that has already occurred (Answer 1). The oxygen is not given to prevent any respiratory complication (Answer 3), nor will the oxygen have an effect on the oxygen-carrying capacity of the RBCs (Answer 4). Focus on the two options with "prevent.” Then note that the word "sickle" is in both the stem and Answer 2 ("sickling") A child is admitted to the hospital with a second attack of rheumatic fever. In doing an admission assessment on this child, which group of symptoms would the nurse most likely find? Petechiae, malaise, and joint pain. Chorea, anemia, and hypertension. Tachycardia, erythema marginatum, and fever in late afternoon. Subcutaneous nodules, dependent edema, and conjunctivitis. The most common symptom in children with rheumatic fever is tachycardia due to cardiac involvement; in addition, these children may develop a rash, "erythema marginatum," and a characteristic fever, which spikes in the late afternoon. They do not usually have petechiae (Answer 1), hypertension (Answer 2), or conjunctivitis (Answer 4). Remember that cardiac symptoms are associated with rheumatic fever; therefore, choose the option with tachycardia A school-age child has leukemia. Considering the diagnosis and health-teaching needs, the nurse would be most correct in advising this child to: Skip brushing the teeth at this time. Brush the teeth with a soft toothbrush only. Brush the teeth with a firm toothbrush only. Rinse the mouth with an antiseptic solution instead of brushing the teeth. Children with leukemia often experience bleeding gums due to thrombocytopenia; in addition, chemotherapy may cause oral mucous membrane ulceration. Therefore, the nurse would be most correct in advising this child to use a soft toothbrush only. Using a firm toothbrush (Answer 3) might cause a break in the gums, leading to infection. Rinsing the mouth only (Answer 4) might also lead to infection, because this would not necessarily clean the gums and teeth adequately; likewise, infection might be caused by not brushing the teeth (Answer1). Narrow your choices to two contradictory options about brushes (soft vs. hard) and choose soft, due to bleeding The mother of a hospitalized 3-year-old tells the nurse that he is a very poor eater at home. The best recommendation the nurse can make to increase his nutritional intake would be to: Provide him with a child-size table. Use plastic cups and plates with cartoon characters he likes. Offer him small portions of his favorite foods. Allow him to feed himself. For a child just leaving the toddler period of autonomy and just entering the preschool period of initiative, the best suggestion to improve his nutritional intake would be to allow the child to feed himself. Other suggestions would supplement and enhance this primary consideration (Answers 1, 2, 3). The major developmental task of the toddler is autonomy; the major developmental task of the preschooler is initiative. Look at the verbs: "provide," "use," "offer," and "allow." Choose "allow." A 3-year-old with hemophilia is to be discharged, and the nurse has completed teaching with the child's parents. Which statement by the parents indicates they may have misunderstood the nurse's teaching regarding the care? If our child gets a fever, we will only give acetaminophen, not aspirin. We will be sure to supervise our child carefully so that our child doesn't experience another bleeding episode. I'll order a Medic Alert bracelet for our child as soon as we get home. It's a relief to know that our little daughter will not get this disease too. It would be impossible to supervise a child with hemophilia so carefully that any other bleeding episodes would be prevented; furthermore, to attempt to do so would cause the parents to restrict the child totally, resulting in extreme over-protection an acceptable alternative response would be to prevent "major" episodes of bleeding or to promptly recognize signs of a bleeding episode that would require medical intervention. The other statements (Answers 1, 3, 4) are all correct responses by the parents, indicating they have probably understood the nurse's teaching regarding the child's care. Note the use of the word "misunderstood" in this question, meaning look for the incorrect statement An infant with CHF takes 1.25 oz of formula in 20 minutes. The doctor ordered 2 oz of formula q3h. The best action for the nurse to take at this time would be to: Ask the mother to feed the infant when she arrives. Burp the infant and try to stimulate sucking. Continue feeding slowly, allowing as much time as the infant needs to finish. 4 Stop the feeding, and request an order for gavage feedings prn. Infants with CHF should be given about 15-20 minutes per feeding; if the infant is unable to finish the feeding, or if the infant becomes cyanotic or experiences respiratory distress during the feeding, gavage feeding should be used to avoid exhausting the infant and possibly precipitating an episode of apnea. No attempts should be made to continue the feeding (Answers 1, 2, 3). Three options continue the feeding and one option stops the feeding. In this case, choose the option that is different. The mother of a child with epiglottitis tells the nurse that she does not even know what epiglottitis is. The nurse would be most correct in telling her that it is: An infection of the upper respiratory tract related to allergy and excessive mucous production. A potentially life-threatening infection that requires prolonged intensive care. A mild form of croup that is usually treated at home. A swelling in the throat that can lead to total airway obstruction if not treated promptly. Epiglottitis is a bacterial infection of the epiglottis resulting in rapid airway swelling and obstruction; without prompt, aggressive treatment, it can progress rapidly, resulting in respiratory arrest within 6 to 8 hours of onset. Although this condition does require hospitalization and is potentially life-threatening, the ICU stay is usually short (Answers 2, 3). There is no allergic cause of epiglottitis (Answer 1). Of all the respiratory conditions of childhood, epiglottitis is the most rapidly progressive (i.e., quickly life threatening and quick to recover, hence short stay in ICU.) On admission, a preschooler is carrying a soiled and worn-looking stuffed animal. His mother states that this is his favorite toy. The most appropriate action for the nurse to take at this time is to: Offer him a choice of another stuffed animal from the hospital playroom. Place this stuffed animal somewhere in his room where he can see it but not touch it. Suggest his mother bring him a new stuffed animal. Tell him that he can keep this stuffed animal in the bed with him. When a preschooler has a favorite "security object," be it a blanket or a doll or a stuffed animal, that child should be allowed to keep the security object, even during hospitalization. This will promote the child's sense of trust and security, thus helping to make the hospitalization a more positive experience. Offering the child another toy (Answer 1), putting the toy where he can see it but not touch it (Answer 2), or giving him a new stuffed animal (Answer 3) will not take the place of the child's old but well-loved original stuffed animal. Preschoolers will regress when stressed. Note that two options allow the security object to remain-one at a distance and the other close by In reviewing a preschooler's admission history and laboratory results, the nurse should know that the two most common findings in children with nephrosis are: Generalized edema and proteinuria. Hyperlipidemia and periorbital edema. Hypertension and hematuria. Oliguria and anorexia. Nephrosis (nephrotic syndrome) is a chronic syndrome characterized by variable pathology and questionable prognosis. In general, most children with nephrosis have severe, total body edema and 4+ proteinuria, along with hypoproteinemia. Hypertension and hematuria (Answer 3), and hyperlipidemia and periorbital edema (Answer 2), are more common in acute glomerulonephritis. The child with nephrosis seldom has severe oliguria (Answer 4), although occasionally this may occur; anorexia (Answer 4) may or may not occur, depending on the severity of the exacerbation. Choose "generalized" edema over limited (periorbital) edema The number one priority during the nurse's admission assessment of a school-age child with rheumatic fever is the child's: Weight. Apical pulse rate. Developmental level. ESR Carditis is the only manifestation of rheumatic fever that can lead to permanent damage; the best way to evaluate a child for the presence of carditis is to monitor the apical pulse at least q4h. 3 (Answers 1, 3) and ESR (Answer 4) deserve secondary consideration after checking the apical pulse. When performing an assessment, priority always implies either heart or lungs In planning care for a teenager in sickle cell crisis, the nurse should base any actions on the knowledge that pain in vaso-occlusive crisis is primarily due to: Increased RBC destruction. Hepatosplenomegaly. Obstruction of small blood vessels. Sequestration of blood. The pain in vaso-occlusive crisis is due primarily to the clumping together of RBCs, which blocks small blood vessels, thus causing tissue ischemia, necrosis, and death. Although there may be increased RBC destruction (Answer 1) and hepatosplenomegaly (Answer 2), this is not the primary cause of this child's pain. Sequestration of blood does not normally occur with sickle cell anemia (Answer 4). Vaso-occlusive crisis implies a blockage (obstruction) in blood flow. Note the similarity of the term in the stem and in option 3 A teenager is preparing the first dose of insulin. The physician orders 14 U of NPH insulin; the teen draws up 13 U and shows it to the nurse. The nurse should base any response on the knowledge that: This is the first attempt and the teenager did come close to the exact dose. At this age, the teenager cannot be expected to make such fine discriminations in dosage. The teenager must draw up the exact amount before administration. Teenagers often antagonize adults subconsciously. From the very first attempt by a child to administer his or her own insulin, the nurse should stress the need to administer exact amounts as ordered by the physician. The child should learn from the start that "close" is not "correct" (Answer 1). A teenager can and should be capable of drawing up the exact amount (Answer 2). Drawing up an incorrect dose does not mean this teen is trying to antagonize the nurse, consciously or subconsciously (Answer 4). Any medication administered must be in the exact amount ordered Between feedings, the nurse should place an infant with CHF in which position? In an infant seat with head elevated. Prone with head turned to side. Supine with head slightly hyperextended. Side-lying with the head of the bed elevated 30 degrees. As with an adult with CHF, the infant should be positioned in a chair/infant seat, in semi-Fowler's position, to provide for maximum expansion of the lungs and to assist the heart placing the infant on the stomach (Answer 2) might be an acceptable second choice, providing the infant can tolerate this position. The infant should never be placed on the back (Answer 3), even with the head slightly hyperextended, because of the possibility of aspiration and other respiratory complications. A side-lying position (Answer 4) would not allow for maximum expansion of the lungs; an infant seat is more appropriate. Picture the various positions and eliminate options 2 and 3. Cardiac rest is best promoted by a semi-Fowler's (i.e., head elevated) position, regardless of the patient's age or condition The doctor attempts to shine a light through myelomeningocele sac and notes "no transillumination." The nurse should interpret this finding to mean that the sac: Can be easily repaired. Cannot be evaluated by this technique. Contains meninges and CSF. Contains meninges, CSF, and the spinal cord. Transillumination, or the procedure of shining a light through the sac, is the usual means for evaluating the contents of the sac. When there is "no transillumination" (the light cannot shine through the sac), this indicates the presence of solid material, or the spinal cord, within the sac. Thus Answers 2 and 3 are incorrect. Transillumination has no bearing on determining whether the sac can be easily repaired (Answer 1). Break up the word transillumination into its respective parts, trans and illumination, to derive its meaning. Choose the option that is most inclusive (3 is included in option 4) After administering syrup of ipecac to a toddler, the nurse should also give: Four ounces of warm milk. Activated charcoal powder. As much water as the child will drink. A slice of dry toast. Syrup of ipecac is an emetic used to induce vomiting following ingestion of a harmful substance; the usual dose in children is 10-15 mL PO followed by at least 200 mL of water. The water is thought to enhance the emetic effect of ipecac and stimulate emptying of the stomach, thus ridding the body of the harmful substance. Activated charcoal (Answer 2) will neutralize the emetic effect and should not be given with ipecac, although in some cases it may be given after vomiting has occurred. Milk or toast (Answers 1, 4) has little or no effect and will neither help nor harm; how ever, if the child does vomit, they may increase the risk of aspiration. Ipecac should always be administered with water After placing a toddler in a croup tent, the nurse should adjust the plastic canopy so that: The edges are tucked tightly under the linen. The edges are lying loosely on top of the linen. The crib rails are raised and the canopy edges are over them. The crib rails are lowered and the canopy edges are inside them. Because oxygen is heavier than room air, it will settle to the bottom of the croupette and leak out unless the edges are tucked in tightly. If the edges are lying loosely on top of the linens (Answer 2), the oxygen will escape, resulting in lower concentrations than ordered. The crib rails should be raised for safety, not lowered (Answer 4); and again the edges should be tucked in tightly, not draped over the rails (Answer 3). Focus on the two options about plastic canopy edges and select "tightly" over "loosely." In what position should the nurse place a child in status asthmaticus? 1. Knee-chest. High Fowler's. Lateral Sims'. Supine, with neck hyperextended. The preferred position for a child with asthma is high Fowler's, or sitting up straight, which allows for maximum expansion of the lungs. Other positions would not allow for the maximum expansion of the lungs (Answers 1, 3, 4) and would only contribute to this child's hypoxia. A full upright position allows for maximum expansion of the lungs A teenager hospitalized with diabetes goes to the teen lounge and becomes very boisterous and aggressive, starting a fight with another teen. The first question the nurse should con sider is: Should he be sent to his room? Did he eat breakfast today? What did the other teen do to him? Does he miss his own friends? Juveniles with diabetes (type 1 diabetes) are extremely brittle, or difficult to control, and prone to episodes of hypoglycemia or ketoacidosis. If this teenager were to experience a hypoglycemic episode, the earliest symptoms would often be behavioral: irritability, personality changes, etc. If this teen becomes disruptive, the nurse should first ask if he has eaten his breakfast, how much he ate, and when; other areas (Answers 1, 3, 4) would be appropriate to explore after this primary consideration. An underlying physiological cause to a patient's behavior should be explored first, before looking at behavioral considerations The nurse has completed discharge teaching with the parents of an infant with ventricular septal defect (VSD) and CHF. Which one statement by the mother would indicate the need for additional teaching by the nurse? I'll be sure to dress our baby in loose-fitting clothes. I'll try to keep my house as warm as 1 can for our baby. I'll be at the clinic in 3 days for the appointment. I'll put the baby in the playpen at least once a day. Extremes of temperatures, either too warm or too cold, should be avoided for infants with CHD, because this increases the body's demand for oxygen, thus increasing the workload of the heart. The mother would need no further teaching if she correctly stated that this infant should be dressed in loose-fitting clothing (Answer 1), should be brought back to the clinic for regularly scheduled appointments (Answer 3), and should be placed in a safe play area to stimulate development (Answer 4). Note the use of the phrase "need for additional teaching" in this question (i.e., look for the incorrect statement) A 7-month-old infant is admitted to the pediatrics unit with moderate dehydration secondary to acute gastroenteritis (AGE). The physician writes all the following orders for this infant. Which one should the nurse implement first'. Contact precautions. IV of 5 dextrose in 'A normal saline solution at 25 mL/hr. Urine specific gravity stat and q4h. With a patient with a potentially contagious infection such as AGE, the first priority is protection of the nurse and other patients by observing appropriate infection control measures, including contact precautions. Other interventions can then be safely implemented without risk of cross- contamination (Answers 2, 3, 4). Infection control is always a priority of care The best advice the nurse can give to parents to handle a toddler's temper tantrums would be to: Allow the toddler to make own choices. Ignore this behavior. Change the setting in which they occur. Give in to the toddler's demands, to nurture autonomy. The general recommendation to make to parents on how to handle temper tantrums is to ignore this behavior. If a parent allows a child to make a choice (Answer 1) and then does not follow through with this choice either because of personal preference or because the choice is unsafe, tantrums will increase. Changing settings (Answer 3) is often a catalyst for a tantrum as the child is moved from one area to another (e.g., from the park to home). Giving in to a toddler's demands (Answer 4) is unrealistic; parents should offer only allowable choices to their toddler and then allow the toddler to follow through with these choices. Paying attention to a temper tantrum will reinforce this behavior. A toddler is admitted to the hospital with classic hemophilia (factor VIII deficiency). Which admission procedure by the nurse will probably be the most frightening for this child? Blood pressure. Rectal temperature. Urine specimen. Weight. Toddlers typically fear those procedures that are "intrusive," that is, where something goes into their bodies. Therefore, a rectal temperature would most likely evoke the most anxiety in a toddler. Generally, a toddler would be relatively cooperative with getting weighed (Answer 4) and giving a urine specimen (Answer 3), although having blood pressure taken might also be somewhat threatening (Answer 1). Note the patterns in the answers: three options are nonintrusive procedures, one option is intrusive—and therefore most frightening In writing a nursing care plan for a child with leukemia, the nurse should include all of the following goals. Which goal is most important and should receive top priority? Maintain infection-free state. Prevent injury. Promote adequate nutrition. Meet developmental needs. The leading cause of morbidity and mortality in children with leukemia is infection; therefore, preventing infection is the most important nursing care plan goal. Preventing injury (Answer 2), promoting adequate nutrition (Answer 3), and meeting developmental needs (Answer 4) are less important goals for the child with leukemia. Infection control is lop priority of care when the immune system is compromised (e.g., in leukemia) The physician orders sterile moist soaks to a myelomeningocele sac. The major reason for this treatment is to: Promote comfort. Prevent infection. Relieve pressure. Stimulate neural development. The chief purpose of the moist soaks is to prevent tears or leaks in the sac, which could lead to infection, the number one cause of death during the neonatal period. Promoting comfort (Answer 1) and relieving pressure (Answer 3) are not reasons for ordering moist soaks for this infant. It is not possible to stimulate neural development (Answer 4), which is permanently and irreversibly arrested before birth. Look at the verbs: "promote," "prevent," "relieve," and "stimulate." Choose "prevent." The night before surgery, as he is getting ready for bed, a preschooler asks his father to "check under the bed for monsters." The nurse would be most correct in advising his father to: Ask the child to talk more about these monsters. Leave a light on and let the child check for himself. Make a game of checking under his bed. Tell him that monsters are only make-believe. By making a game of "checking for monsters," a potentially frightening situation is relieved, and the child may even begin to realize that there "really" are no monsters asking the child to talk about his monsters (Answer 1) may make him believe they are real and that his father also believes in them. It would be too frightening to the child to have to look for these monsters by himself (Answer 2). Telling a preschooler that his fantasies are not real (Answer 4) would not be enough to convince him and might make him become even more convinced they are real. Preschoolers are in the age of fantasy or magical thinking; therefore choose option 3, "make a game." Following surgery to correct hypospadias, a toddler returns to the unit with a Foley catheter in place. The nurse should expect the drainage to have: A clear yellow appearance. Small clots of blood or mucus. Gross hematuria in moderate amounts. A brownish tinge. The surgical repair for hypospadias is done on the urethra primarily and also on the urethral meatus. Postoperatively, a urinary drainage apparatus (Foley or suprapubic) will be in place, and the urine is expected to have a clear yellow appearance. There should normally be no blood or mucus (Answers 2,3,4), which would indicate hemorrhage or infection if present. Choose the option that is different: three options indicate a problem, one says it is OK (yellow urine is normal) A child with cystic fibrosis is to receive replacement pancreatic enzymes several times daily. The best time for the nurse to plan to administer this medication is: After every meal or snack. Between meals and after every snack. Immediately before meals or snacks. With meals and before snacks. To be most effective, pancreatic enzymes should be administered immediately before every meal and every snack; this will facilitate the absorption of fats and proteins contained within the meal. The enzymes will have little or no therapeutic value if given at other times (Answers 1, 2,4). Key word is "replacement" of what is missing in CF; therefore, the best time to aid fat absorption is before eating In addition to administering oxygen, the nurse can also relieve the pain experienced by a teenager in sickle cell crisis by: Applying warm compresses. Applying cold compresses. Performing passive ROM exercises. Performing ADL as needed. Warmth causes vasodilation, thus relieving the occlusion of small vessels and preventing tissue damage. Cold (Answer 2) would never be used, because it causes vasoconstriction. Performing ROM exercises (Answer 3) or ADL (Answer 4) would not relieve pain. Focus on two options that are contradictory: warmth —> vasodilation; cold —> vasoconstriction. Occluded blood vessels need vasodilation measures The nurse observes a nursing student fastening an infant's diaper snugly around the abdomen; the infant has CHF. The nurse should: Ask the student to loosen the diaper. Do or say nothing, as this is expected behavior for a student. Loosen the diaper after the student leaves the room. Praise the student for outstanding attention to detail. An infant with CHF should wear loose-fitting clothes, including diapers, to avoid pressure on the abdominal organs, which could impinge on the diaphragm and impede respiratory effort. The nursing student should loosen the diaper and should know the rationale for this action as well. The nurse should not take care of this after the student leaves (Answer 3), because the student will repeat the mistake without the nurse's intervention; in addition, pinning the diaper snugly is inappropriate for an infant with CHF (Answers 2,4), and the nurse has the final responsibility for the care this infant receives. Any patient with CHF, regardless of age, should wear loose fitting clothes Which statement by the parents of a preschooler with nephrosis indicates that they have fully understood the nurse's teaching? We will keep him away from other children so he doesn't get a relapse. We're so glad this is all over and we don't have to worry any more. When we get home, we're going to find it hard to keep him in bed. We will watch him for any signs of this starting up again. Nephrosis is characterized by periods of exacerbations and remissions that occur throughout the childhood years. The child's parents should watch him closely for exacerbations, which should be reported promptly to the physician. The child should be encouraged to play with other children, not to stay away from them (Answer 1) to avoid feelings of social isolation. It is not "over" (Answer 2), and the child will need to be watched carefully for periods of exacerbation. Once the child is discharged, he will generally not need to remain in bed (Answer 3) but rather can convalesce at home with alternating periods of activity and rest. Note the use of the words "fully understood" in this question; therefore, use a true-false approach to eliminate the three false statements A child with leukemia is receiving vincristine. The nurse should observe this child closely for the side effect of: Diarrhea. Diplopia. Hemorrhagic cystitis. Peripheral neuropathy. Vincristine is an antineoplastic Vinca alkaloid, which causes numbness, tingling, footdrop, paresthesia, etc. In addition, vincristine may also cause constipation, not diarrhea (Answer 1). Hemorrhagic cystitis (Answer 3) may be caused by cyclophosphamide (Cytoxan), not vincristine. Vincristine does not cause visual changes (Answer 2). Know the major side effects of vincristine (peripheral neuropathy) A 6-year-old with cystic fibrosis refuses to swallow the replacement pancreatic enzyme tablets. The best course of action for the nurse would be to: Check with the doctor about discontinuing this medication. Crush the tablets and mix with 1 teaspoon of cold applesauce. Dissolve the tablets in 4 oz of warm milk. Offer the child a "special treat" for swallowing the tablets "like a big kid." Pancreatic enzymes are enzymes; as such, they breakdown whatever food or liquid they are mixed with. However, for maximum therapeutic effect, the enzymatic action should be delayed until the medication reaches the stomach. The best food to mix with pancreatic enzyme tablets is the cold applesauce. The applesauce should be cold because cold delays the enzymatic action, which is most effective at 98.6°F. Applesauce is used because of its high fiber content, which also delays the enzymatic action of the medication any other foods or liquids the pancreatic enzymes might be mixed with (Answer 3) would be less than ideal. Pancreatic enzyme tablets cannot simply be discontinued (Answer 1) because a child has difficulty swallowing them; this medication must be taken for the rest of the child's life. It is not appropriate to bribe a child (Answer 4) with a reward for desired behavior; children should never be bribed or threatened into taking medication. Focus on the two options with contradictory terms: cold vs. warm. Cold has the desired effect of delaying enzymatic action A school-age child experiences the following signs or symptoms of rheumatic fever. The nurse should plan any interventions based on the knowledge that the only one that may result in permanent damage is: Sydenham's chorea. Migratory polyarthritis. Carditis. Erythema marginatum. Carditis can lead to permanent, irreversible cardiac damage, specifically, mitral valvular stenosis. The other manifestations of rheumatic fever (Answers 1, 2, 4) are transient and do not leave any permanent effects. Key word is "permanent." Choose the option pertaining to the heart. The best roommate for a 9-year-old girl with rheumatic fever would be: An 8-year-old girl with impetigo. A 9-year-old girl with a tonsillectomy. A 10-year-old girl with a concussion. An 11-year-old girl with a fractured elbow in skeletal traction. A child with rheumatic fever will be in the hospital for a relatively longer time and will be confined to bed most of the time. The ideal roommate would be another child of the same sex and same developmental level who will also be in the hospital for some time and confined to bed. The best choice is the young girl with the fractured elbow, who will be in skeletal traction and also on bed rest. The child with a tonsillectomy (Answer 2) or the child with a concussion (Answer 3) will most likely be in the hospital for a very short time and will be out of bed. The child with impetigo, caused by streptococcus (Answer 1), would be a most unsatisfactory roommate for this child, because she might reinfect her with strep. The ideal roommate for any child is another child of the same sex and developmental level The nurse should be aware that the most important nursing diagnosis in caring for a child with diabetes is: Risk for injury related to insulin deficiency. Altered family processes related to situational crisis (child with chronic disease). Knowledge deficit related to care of a child with diabetes. Altered body image related to treatment of diabetes. The most important nursing diagnosis relates to physiological integrity (i.e., maintaining a normal blood-sugar level). Other diagnoses (Answers 2, 3, 4) would be correct but not necessarily of primary concern. Physiological integrity is always a priority of care An infant with myelomeningocele is scheduled to have surgery to close the sac. The mother asks the nurse if the baby will be able to move the legs following this operation. The best response for the nurse to make would be: Not usually, although we can always hope for a miracle. There is no way to predict. All we can do is watch the baby closely. No, the surgery is done mainly to prevent infection. Yes, the surgery will restore the ability to move the legs. Parents often hope that the surgery done to close the sac will also help the infant move the legs. Surgery will not enable the infant to regain motor or sensory functioning; surgery is done primarily to prevent infection. Parents should not be told the infant will move the legs after surgery (Answer 4) or offered false hope (Answers 1, 2). Myelomeningocele results in permanent, irreversible nerve damage The best method to prevent the spread of infection from an infant with AGE to other staff members or visitors would be: Double-bagging all linens. Obtaining stool cultures. Strict hand washing. Wearing disposable gloves. The best means to prevent any type of infection in any type of setting is good hand washing. Other techniques are secondary (Answers 1,2,4). Hand washing is the first line of defense in infection control At 7 months of age, an infant exhibits the following skills. The nurse should know that the most recently acquired skill is probably the ability to: Roll over. Sit up. Bear some weight on legs. Pick up objects with palmar grasp. At 7 months of age, an infant may either sit with some support or sit alone; either behavior is commonly acquired at this age. Rolling over (Answer 1) is usually found in infants around 3 to 4 months of age, whereas weight bearing (Answer 3) and the palmar grasp (Answer 4) are commonly found in infants between ages 4 and 6 months. Note the use of the phrase "most recently acquired skill" in this question The most appropriate person to administer a preoperative series of cleansing enemas to a 9-month-old with Hirschprung's disease would be the: Primary nurse. Mother. Nursing student. Nursing assistant. As a 9-month-old with a chronic bowel problem, this infant has probably become accustomed to mother's administering suppositories or enemas. In addition, fear of strangers is common in this age group. Considering these factors, this infant's mother should at least be offered the opportunity to administer or assist with the enemas. If this is not feasible, another qualified person could take her place. (Answers 1, 3,4). Look at the pattern of responses: three options are staff, one is the mother. Choose the one that is different, especially considering that fear of strangers peaks at 8—9 months On admission, the nurse would expect a toddler to demonstrate which two early signs of laryngotracheobronchitis (LTB)? Cyanosis and apnea. Hoarseness and croupy cough. Restlessness and tachypnea. Retractions and inspiratory stridor. LTB progresses through four distinct stages, with early symptoms in the first stage including fear, hoarseness, croupy cough, and inspiratory stridor only when disturbed. In the second stage, the stridor is constant and is accompanied by retractions (Answer 4). In the third stage, restlessness and tachypnea (Answer 3) are seen in addition to anxiety, pallor, and sweating. In the fourth and final stage, intermittent or constant cyanosis is followed by the cessation of breathing, or apnea (Answer 1). Note the use of the words "early signs" in this question A diagnosis of bacterial meningitis is confirmed, and the child assumes an opisthotonos position. In which position should the nurse now place this child? Prone. Supine. Side-lying. Trendelenburg. The opisthotonos position occurs in children with severe meningitis due to the pressure on the spinal cord; the child's head is drawn back and the spine is arched backward in an attempt to minimize pressure on the cord. When the child assumes this position, the nurse should place the child in a side-lying position for safety and comfortany other position would not work as well (Answers 1, 2, 4). Visualize the condition, and then visualize the options to identify the position for safety and comfort In planning a roommate for a hospitalized 12-year-old girl, the nurse should realize that a child of this developmental level will: Probably prefer another girl her own age. Most likely seek out opportunities to socialize with teenagers. Enjoy being with either a girl or boy, as long as they are the same age. Feel helpful if given the opportunity to look after a slightly younger child. Younger teenage girls in particular prefer the company of other young girls; they have a definite preference for same- sex, same-age companions as such, this child would not necessarily seek out older or younger children (Answers 2, 4), nor would she have "no preference" regarding the sex of her companion (Answer 3). Know age-relevant stages of psychosocial development. Young teenage girls generally prefer a same sex "best friend." In teaching a teenager how to prevent further episodes of sickle cell crisis, the nurse should stress the need to avoid: Moderate emotional stress. Cool weather. Swimming in public pools. Extra fluid consumption. Crises are precipitated by conditions of low oxygen tension; this may include infection, which could easily be picked up by swimming in public pools. Other sources of low oxygen tension might include severe emotional stress (Answer 1), extremely cold or windy weather (Answer 2), or dehydration (Answer 4), as well as high altitudes. Note the use of the word "avoid" in this question, and situations that may lead to infections If a child who was given syrup of ipecac has not vomited within 30 minutes, the nurse should: Stimulate the gag reflex using his or her fingers. Wait another 30 minutes before doing anything else. Assume the danger is past and no further treatment is needed at this time. Repeat the dose a second time. With children who have received a 10 mL dose of syrup of ipecac, if vomiting has not occurred within 30 minutes, the dose can and should be repeated once more. Although the first dose is generally effective in the majority of cases, a second dose is almost always 100% effective. If the child does not vomit after a second dose, manual stimulation of the gag reflex or gastric lavage must be promptly initiated to avoid toxic effects of ipecac. The nurse should never use fingers to stimulate the gag reflex (Answer 1), especially in a toddler, because of the danger of receiving a human bite. Ipecac works within 15—30 minutes, and waiting another 30 minutes will not be helpful (Answer 2). If the child does not vomit at all, thus not removing either the ipecac or the ingested substance(s), there is the danger of ipecac toxicity, as well as poisoning from the ingested substance (Answer 3). Eliminate 2 (do not wait) and 3 (there is a danger) because ipecac is cardiotoxic and can cause complete heart block The physician orders "increase activity as tolerated" for a school-age child with carditis associated with rheumatic fever. After getting the child up into an armchair, the nurse should monitor how well this increase in activity is tolerated by checking the: Apical pulse rate. Breath sounds. Degree of restlessness. Lips and nailbeds. Due to this child's carditis, the best means for the nurse to evaluate how well any increase in activity is tolerated would be by monitoring the apical pulse rate any increase in pulse rate over 15—20 beats/min would indicate that the increase in activity is not tolerated and would be an indication for returning the child to bed immediately any other method of evaluating tolerance of increasing activity would be less effective (Answers 2, 3, 4). Activity tolerance in heart conditions (carditis in rheumatic fever) is best measured by heart rate About a week after discharge, a teenager newly diagnosed with diabetes and his mother return to the clinic for a checkup. His mother states, "I'm worried he will make a mistake, so I've been giving him his insulin." The nurse should: Allow the teenager and his mother to work this out on their own. Assist his mother to understand that he must assume this responsibility. Encourage his mother to continue working closely with him. Realize that this is an appropriate response by the mother. The teenager who is newly diagnosed with diabetes must assume responsibility for his own care as soon as possible; diabetes is a chronic disease with no known cure that this teen will have to live with for the rest of his life. The nurse should discourage his mother from being overly protective of him or from assuming this responsibility (Answers 1, 3, 4). Self-care management is always a patient-centered goal The mother of a hospitalized infant with CHF asks the nurse why the baby is sucking on a pacifier. The nurse would be most correct in telling her: The baby seems to like it. Most infants prefer a pacifier to their thumb. This is to keep the baby from crying. We give all hospitalized infants a pacifier. The use of a pacifier for an infant with CHF will promote true psychological rest, thus reducing the body's demand for oxygen and reducing the workload of the heart. This is the most important reason that this infant should be offered the pacifier; although it may also be true that the infant seems to like the pacifier (Answer 1), this is not the main reason one should be given answers 2 and 4 are too generalized and not necessarily true. According to Freud, because infants are in the stage of oral gratification, a pacifier will reduce crying, which is medically significant in this case The first night in the hospital, a child with hemophilia suffers an episode of epistaxis. In which position should the nurse place this child? Prone, with head turned to side. Semi-Fowler's with two pillows. Sitting up with head tilted backward. Sitting up and leaning forward slightly. Contrary to popular belief, the best position for the nurse to place a child with a nosebleed in is sitting up and leaning forward slightly, with head remaining above the level of the heart; this position will allow the blood to drain freely from the nose and prevent aspiration. Sitting up with the head tilted backward (Answer 3) will predispose the child to swallowing or aspirating blood, as will a semi-Fowler's position (Answer 2). The prone position (Answer 1) might be an acceptable second choice if the child were too weak to sit up without assistance. Preventing aspiration and maintaining a patent airway is always a priority of care Nursing care for a toddler in the croupette includes which of the following? Giving a bald plastic doll. Removing the blanket and pajamas. Restraining the arms and legs. Restricting visitors to the immediate family. While in the croupette, toddlers should be allowed only those toys that can be dried off easily; all stuffed animals, dolls with hair, etc. are not allowed, because they will harbor moisture and bacteria. While in the croupette, the child and the linens will also get damp or wet, and the nurse should implement measures to prevent chilling. Pajamas and blankets should be changed q4h or prn (Answer 2). There is no need to restrain a child in the croupette (Answer 3), because all working parts are safely outside the croupette. There is no need to restrict visitors (Answer 4). Infection control is always a priority of care. Look at the verbs in the stem: "giving," "removing," "restraining," and "restricting." "Giving" is preferable; it sounds better than the 3 r’ s The mother of a child with cystic fibrosis tells the nurse that she is thinking of getting pregnant again but is worried that her next child might also have cystic fibrosis. Because her child does have this disease, the nurse should advise this mother that a second child: Could be even more severely affected than her first child. Might also have the disease. Should be "normal," or disease free. Would only carry the trait. Cystic fibrosis is inherited as an autosomal recessive disorder. The fact that these parents have a child with CF means that they are carriers of the trait, and each subsequent pregnancy might result in a child who also has CF. It would not be correct to advise the mother that a second child would only carry the trait (Answer 4) or would be normal (Answer 3), although there is a possibility these might occur; the parents should be fully advised of the odds of this happening. In addition, it would needlessly worry the parents to tell them a second child might be more severely affected (Answer 1), although this is also a possibility. Regardless of the genetics, having had one child with this disease, there is always a risk that subsequent children may also have this disease A child has had asthma since age 6. In reviewing this child's history, which one factor should the nurse realize may be related to the development of the asthma? Strep throat/tonsillitis at age 2. Eczema at age 3Vi. Paternal death at age 5. Pneumonia at age 7. About half the children who have eczema during the toddler or preschool years develop asthma during the school-age or teenage years asthma seems to have little or no relation to strep throat or tonsilitis (Answer 1). The father's death undoubtedly would have affected this child, but it occurred 1 year before the onset of the asthma (Answer 3). The pneumonia experienced at age 4 might have been related to the asthma, but was not the cause of it (Answer 4). Although the etiology of asthma is multifactorial, there is thought to be an allergic predisposition Which one behavior should the nurse expect a 5-month-old with CHF to be capable of demonstrating? Rolling over from stomach to back. Sitting with support. Pincer grasp. Bearing some weight on legs. Considering this infant's diagnosis, the nurse should anticipate that the infant will most likely have at least some developmental delays; most infants would begin to roll over by 3 months of age, but at 5 months the baby should be doing this now. Sitting (Answer 2) is normally found around 6 months of age; this infant will most likely not be capable of this behavior at 5 months. A pincer grasp (Answer 3) is normally found at 9-12 months of age, and this infant will most likely not be capable of this behavior. Weight bearing (Answer 4) is typically noted in healthy infants at 4-6 months of age; considering this infant's diagnosis, however, this baby may or may not be capable of this more strenuous behavior. Infants learn to roll over at 3 months, sit at 6 months, and crawl at 9 months. Consider delayed development in congestive heart failure Following surgery to close the myelomeningocele sac, the nurse should place the infant on the: Abdomen, with head 10 degrees lower than hips. Abdomen, with head of bed elevated 30 degrees. Abdomen, with hips 10 degrees lower than head. Abdomen, flat in bed. The infant is placed on the abdomen postoperatively to prevent trauma or pressure to the sutured area on the back. In addition, the infant's head should be positioned 10 degrees lower than the hips to prevent the pressure of circulating CSF from affecting the suture line on the lower back an obvious contraindication to this position is the presence of increased intracranial pressure, in which case the infant would be positioned flat in bed (Answer 4). In general, the head is never higher than the hips (Answers 2,3) during the immediate postoperative period for this type of surgery. Visualize the positions; know postoperative objectives regarding preventing pressure to suture area Parents of an infant with Hirschsprung's disease ask the nurse how their baby got the disease. The nurse would be most correct in advising them that: Their baby was born with this condition. It is the result of the meconium ileus the baby experienced as a newborn. Their baby spontaneously developed this condition. It often occurs following the introduction of solid foods due to a genetically inherited metabolic defect. Hirschsprung’s disease is a congenital condition. It does not "develop spontaneously," although the diagnosis may not be made until symptoms have been present for several months and some attempts at conservative medical treatment (enemas, stool softeners, etc.) have been made (Answer 3). In the newborn with Hirschsprung’s disease, there may be an episode of meconium ileus (Answer 2), but this occurs as a result of the Hirschsprung’s disease rather than as the cause of it. There is no known metabolic defect (Answer 4). Narrow your option to the one that is different: congenital vs. acquired after birth As a toddler recovers from meningitis, the nurse should watch carefully for which long-term complication? Encephalitis. Hydrocephalus. Learning disabilities. Mental retardation. As healing of the pathways of the CSF occurs following an episode of meningitis, scar tissue naturally forms; this may lead to noncommunicating hydrocephalus. The hydrocephalus might then lead to learning disabilities (Answer 3) or mental retardation (Answer 4). Encephalitis (Answer 1) may occur in conjunction with the meningitis, but it is not a complication. Note the use of the term long-term complication in this question, and select the option that incorporates (leads to two other conditions) or is in conjunction with the other options In reviewing what he would do if he experienced a hypoglycemic episode, a teenager correctly slates that he would eat a piece of candy or drink a glass of orange juice. The nurse should then instruct him to follow this concentrated sweet with: A blood glucose level. A urine dipstick for glucose. A glass of milk. 5 U of regular insulin. Because concentrated sweets will cause a rise in blood sugar, followed by a precipitous drop, the nurse should teach this patient that he should follow up this concentrated sweet with a complex carbohydrate such as a glass of milk any other action would be inappropriate at this time (Answers 1, 2, 4). The complex carbohydrate will help maintain a steady blood sugar level. Therefore, choose the only option that is not a diagnostic Test or pharmacological agent. The mother of a child hospitalized with asthma asks the nurse what causes asthma. The nurse would be most correct in telling her the cause is: Unknown. Allergies. Stress. Multiple factors. There are multiple factors involved in the etiology of asthma, including an allergic predisposition (Answer 2), precipitation by severe emotional or physical stress (Answer 3), and other factors yet to be determined (Answer 1). When more than one option looks correct, choose the more comprehensive answer (multiple answers = "multiple factors") Long-term follow-up care is being planned for a school-age child with rheumatic fever before discharge from the hospital. This must include: Indefinite antibiotic therapy. Immunization against future attacks. Cardiac rehabilitation program. Home-bound tutoring. Long-term follow-up care for children with rheumatic fever most frequently includes antibiotic therapy with penicillin or erythromycin on an exact schedule for an indefinite time. There is no way to immunize against future attacks (Answer 2). This child will be sent home on restricted activity, and cardiac rehabilitation programs are out of the question at this time (Answer 3). Home tutoring would be fine, but it is not a priority at this time (Answer 4). Medical prevention is the clue to the best choice A preschooler has been admitted with a tentative diagnosis of epiglottitis. A medical student wants to look down this child's throat to visualize the epiglottis. The nurse would be most correct in: Asking the child's mother if she objects to the medical student checking her child. Telling the medical student that this absolutely cannot be done. Promising the child a special treat for "opening real wide for the doctor." Helping restrain the child so the medical student can get a better look. In suspected cases of epiglottitis, the visualization of the epiglottis is strictly contraindicated, because it may precipitate laryngospasm and immediate respiratory arrest. It is a nursing responsibility to inform any less knowledgeable health care providers of this danger; any other action (Answers 1, 3, 4) would be inappropriate at this time. The nurse must always serve as a patient advocate. Also note that three responses allow the procedure, but one does not. Choose the one that is different from the others A preschooler with nephrosis is started on prednisone. If the prednisone is having the expected therapeutic effect, the nurse should expect that this child will: Experience mood swings. Have sugar in the urine. Gain weight. Feel better. There is no known cure for nephrosis; rather, treatment is aimed at providing symptomatic relief. To that effect, prednisone—an anti-inflammatory corticosteroid is given to relieve symptoms rather than effect a cure. If prednisone has the expected therapeutic effect, the patient should report "feeling better" as symptoms are relieved. Side effects of prednisone therapy may also include mood swings (Answer 1), glucosuria (Answer 2), and fluid retention with weight gain (Answer 3). Note the key words "expected therapeutic effects," not side effects A toddler who is being placed in a croupette cries and tries to cling to the mother. The mother asks the nurse if she can climb into the crib and lie in the tent with the toddler. The nurse's best response would be: Do you always let your child behave this way? I'll have to check with the doctor first. No, that would not be safe for you or the child. It may help the child calm down; let's give it a try. Toddlers will suffer the most if separated from their mothers; a croupette is a particularly frightening experience, because explanations are difficult. If the toddler will calm down with the mother in the croupette, this will decrease the body's need for oxygen. There is no need to check with the physician (Answer 2), nor would it be "unsafe" (Answer 3). Considering that the child is hospitalized and most likely frightened by the strange equipment, there is no reason to question the parent's handling of the situation (Answer 1). First, decide if this is OK or not OK. Recall that toddlers are at a peak age for separation anxiety, and choose an "OK" answer In a 2-week-old infant, the earliest sign of hydrocephalus that the nurse would observe is: Bulging anterior fontanel. Increasing head circumference. Shrill, high-pitched cry. Sunset eyes. In infants, the earliest sign of hydrocephalus is increasing head circumference, which occurs as the suture lines separate and the fontanels widen to accommodate the extra fluid within the skull. Later signs would indicate that no further accommodation can occur and brain tissue is being destroyed; these signs might include bulging anterior fontanel (Answer 1), shrill, high-pitched cry (Answer 3), and sunset eyes (Answer 4). Note the use of the term earliest sign in this question A child with leukemia who is receiving chemotherapy develops oral ulcers. Three of the following are appropriate nursing interventions; which one is inappropriate? Encourage the child to use viscous lidocaine (Xylocaine) before meals. Offer the child a bland, moist, soft diet. Use a soft tooth brush. Provide frequent normal saline mouth rinses. Viscous xylocaine is never recommended for children with mucosa ulcerations secondary to chemotherapy, because of the risk of a depressed gag reflex and aspiration. The other interventions (Answers 2, 3, 4) are, however, all appropriate nursing interventions. Note that this question is asking about an intervention that is not appropriate, meaning eliminate the correct statements A child with nephrosis has a swollen scrotal sac. Which nursing action would be most effective in relieving discomfort? Apply zinc oxide to scrotum qid. Cleanse scrotum with warm water only. Sprinkle medicated powder on scrotum. Support scrotum on folded diapers. As generalized edema progresses, in males the scrotal sac can become extremely swollen, tender, and painful. The best nursing intervention is to place soft, folded diapers under the scrotum while the child is lying in bed. Zinc oxide (Answer 1) or medicated powder (Answer 3) will have little beneficial effect because the problem is mechanical rather than on the skin itself. Cleansing the scrotum (Answer 2) is important to prevent infection, because all edematous tissue needs special care to prevent skin breakdown; however, this will not relieve the child's discomfort. Providing comfort is the priority of care The surgeon orders a preoperative series of cleansing enemas for an infant with Hirschsprung's disease. The nurse should expect the solution ordered for these enemas to be: Soapsuds enema (SSE). Normal saline. Pediatric Fleets. Tap water. The only solution that should be used in doing cleansing enemas for a child with Hirschsprung's disease is normal saline, because the child will retain some of this fluid, which will be absorbed through the bowel wall as an isotonic solution, normal saline will not alter the fluid balance, as a non-isotonic solution almost certainly would (Answers 1, 3, 4). The choice is between isotonic and non-isotonic solutions. Select the isotonic solution In doing the admission assessment, the nurse should expect to find which signs of dehydration in an infant? Fever and bradycardia. Irritability and sunken eyeballs. Hypotension and anuria. Dry mucous membranes and bulging anterior fontanel. Signs of dehydration in infants include irritability and sunken, dry eyeballs due to fluid loss. Fever may be present, and tachycardia, not bradycardia (Answer 1), is also common. Low blood pressure often results, followed by oliguria; anuria (Answer 3) is rare and would be an ominous sign of renal failure. The oral buccal mucosa may be quite dry, and the anterior fontanel may be sunken, not bulging (Answer 4). If part of an answer is right but part of it is wrong, the answer must be wrong If a toddler were to develop hydrocephalus, which would be the earliest sign(s) the nurse would most likely note? Irritability and poor feeding. Increasing head circumference. Headache and diplopia. Ruptured retinal vessels. If a toddler were to develop hydrocephalus, the first sign would most likely be irritability and poor feeding due to increased intracranial pressure. The head circumference would not increase (Answer 2), because the fontanels have closed. Headaches or double vision might occur (Answer 3), but a toddler is not likely to complain of them. Ruptured retinal vessels (Answer 4) are a later sign of increased intracranial pressure. Note the use of the word "toddler," not infant, in this question The mother of a child with cystic fibrosis asks the nurse if the child will be allowed to participate in any team sports now that he is starting school. The nurse would be most correct in advising her that the child can participate in: Softball. Tennis. Soccer. Swimming. The best exercise for a child with cystic fibrosis is swimming, which provides needed exercise at an activity level that is not overly taxing for the child. Softball, tennis, and soccer (Answers 1, 2, 3) arc all generally thought to be too strenuous for a child with CF. "Swimming" is the option that is different from the others, which all call for ball playing Parents of a child with sickle cell anemia both have the sickle cell trait. In counseling these parents about having another child, the nurse would be most correct in telling them that future pregnancies will have a: 1:4 chance of producing a child with sickle cell anemia. 1:2 chance of producing a child with sickle cell anemia. 1:4 chance of producing a child with sickle cell trait. 4:4 chance of producing a child with sickle cell anemia. Because sickle cell anemia is inherited as an autosomal recessive disorder, if both parents have the trait, any future pregnancies would have a 1:4 (not 4:4 as in Answer 4) chance of producing a child with sickle cell anemia answer 2 is incorrect because each pregnancy would have a 1:2 chance of producing a child with the trait answer 3 is incorrect there is a 1:4 chance of producing a normal child answer 4 is totally incorrect. Autosomal recessive disorders have a 1:4 chance of occurring when both parents are carriers of the trait A patient with hemophilia is to receive Factor VIII concentrate. During the infusion of this medication, the nurse should plan to observe this patient for which potential complications? Emboli formation. Fluid volume overload. Onset of AIDS. Transfusion reaction. Factor VIII concentrate is a blood product; a type and crossmatch may be ordered for the child before the IV administration of this medication. Given the relatively small volume of fluid to be administered, it would not usually cause fluid volume overload (Answer 2). Although there has been some discussion about administering multiple IV medications to a patient with hemophilia and the linkage to AIDS (Answer 3), this is not a concern during the actual administration of the medication but rather a long-term concern. Emboli formation (Answer 1) can occur with any IV administration and is not specific to cryoprecipitate, although the nurse would need to take the necessary precautions to prevent this possibility. Any patient receiving blood or blood products should be closely monitored for a possible transfusion reaction A preschooler with epiglottitis is admitted to the hospital and is to receive Solu-Cortef 100 mg IV q6h. The main purpose for this medication is to: Provide mild sedation. Reduce swelling. Relieve pain. Treat infection. Solu-Cortef is a corticosteroid/anti-inflammatory used in epiglottitis to relieve edema. Solu-Cortef does not provide sedation (Answer 1) or relieve pain (Answer 3), and the bacterial infection is treated with antibiotics (Answer 4). Recall that this is a steroid; recall its function and recall that edema is a main concern in this condition. Therefore, reduction of swelling to keep airway patent is a priority A child with leukemia is being discharged, and the doctor suggests an immediate return to school. The nurse should be sure to teach the parents to keep this child home if any classmates develop: Impetigo. Strep throat. Pneumonia. Chickenpox. Although any infection can be life-threatening to a child with leukemia, chickenpox presents a particular danger, because the child may develop encephalitis or sepsis. Infections such as impetigo (Answer 1), streptococcus (Answer 2), or pneumonia (Answer 3) are less specific dangers. Choose the option that can result in encephalitis, a specific danger In discharge teaching with the parents of an infant with VSD and CHF, which one visitor should the nurse discourage from touching or holding this infant? An aunt, who has lupus. A grandmother, who has a slight cold. The father, who is a drug addict. A 3-year-old sister, who is in nursery school. Because infants with VSD and CHF have a tendency toward respiratory infections, the infant should have limited contact with visitors with URIs, such as the grandmother with her slight cold. In fact, her slight cold might mean an episode of pneumonia for this infant. Lupus (Answer 1) in the aunt is not contagious, nor is the father's drug addiction (Answer 3). The sister (Answer 4) should be allowed to see and touch the infant, unless she herself is sick. Respiratory infection control is the priority of care In monitoring a toddler for response to syrup of ipecac, the nurse should base any actions on the knowledge that ipecac is potentially: Cardiotoxic. Hepatotoxic. Nephrotoxic. Neurotoxic. The chief danger of ipecac's being absorbed into the body is that it can cause cardiac arrhythmias, atrial fibrillation, or severe heart block. There is minimal effect on the liver (Answer 2), kidneys (Answer 3), or CNS (Answer 4). Ipecac can cause cardiotoxicity A mother who lost her first-born to SIDS tells the nurse that she plans to breastfeed her second baby to prevent this from happening again. The nurse should base any response on the knowledge that: The risk of SIDS is the same, however infants are fed. Breastfeeding does seem to prevent SIDS. SIDS occurs less frequently in infants who are bottlefed. Breastfeeding is contraindicated for siblings of infants who died from SIDS. The most recent research indicates that infants who are breastfed do have a lower incidence of SIDS than bottle-fed infants. It is not true that bottle-fed infants have a lower risk of SIDS (Answer 3), nor is it true that the risk of SIDS is the same (Answer 1) however infants are fed. Breast feeding is not contraindicated for siblings of infants who died from SIDS (Answer 4); in fact, breastfeeding in this instance is recommended. Breastfeeding is generally recommended for all infants whose mothers express an interest and willingness to do so Normally, an infant's birth weight doubles by age 6 months and triples by age 1 year. By what age should the nurse expect the birth weight to quadruple? 18 months. 2 years. 2'/2 years. 3 years. Generally, infants who weigh 7 lb at birth will weigh 28 lb, or quadruple their birthweight, by 2Yi years of age. Consequently the other listed ages are incorrect (Answers 1, 2, 4). Know 3 milestones to choose the only correct answer A mother asks the nurse how tall her child will be when grown up. What answer should the nurse offer? This is virtually impossible to predict. It will be double the child's height at 2 years of age. It will be triple the child's height at 18 months of age. Add 2 feet to the child's height at 4 years of age. The general rule of thumb to predict a child's height as an adult is to double the child's height at 2 years of age. The other answers (Answers 1, 3,4) are incorrect. Know developmental milestones to pick the only correct answer In teaching principles of poison control to a group of mothers, the nurse would be most correct in stressing that the age group most likely to suffer from accidental ingestions is: 6-18 mo. 12 mo-2'/2 yr. 2-4 yr. 3-5 yr. Poisoning is most common in toddlers, who have the motor skills necessary to reach the poisons yet lack the intelligence to know not to ingest the poison. The other answers (Answers 1, 3, 4) are, therefore, incorrect. Know age-relevant safely concerns In deciding which one type of accident prevention to discuss first with the parents of a toddler, the nurse should base the choice on the knowledge that most deaths in children under age 3 are caused by: Aspiration/suffocation. Falls. Motor vehicles. Poisonings. In children under 3 years, most accidental deaths are related to motor vehicles in which the child is a passenger; other types of accidents are not as common or not as likely to result in death (Answers 1,2,4). Know age-typical cause of accidental death The following four children are patients in the pediatrics unit. Which one should the nurse anticipate will he mod affected by separation from parents? A 6-week-old with pyloric stenosis. A 19-month-old with salicylate poisoning. A 3'/--year-old with hypospadias. A 5-year-old with hemophilia. Toddlers always suffer when separated from their parents, more so than any other age group (Answers 1,3,4). In fact, the years between ages 1 and 3 are when children are most likely to suffer separation anxiety. It is the age, not the condition. Toddlers are at the peak age for separation anxiety In assessing the development of a 5-year-old, the nurse would not expect the child to be able to: Name primary colors. Count to 100. Know the days of the week. Give telephone number and address. Five-year-olds may count up to 20 or 2b, but seldom beyond this. They should be able to name colors such as red, green, and blue (Answer 1). In addition, they should be able to give their phone number and address (Answer 4) and have a better sense of temporal relationships, as evidenced by their ability to name days of the week, months of the year, and seasons (Answer 3). The stem asks for what this child is not expected to do. The nurse should be familiar with developmental norms found in the DDST An RN from the telemetry unit is floated to the pediatrics unit. The charge nurse must assign three patients to her. Which patient should not be assigned to the telemetry nurse? A 5-month-old with Kawasaki disease. A 9-year-old with rheumatic fever. A 4-year-old with VSD after cardiac catheterization. A 3-week-old after pyloromyotomy. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen answer 1 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients with cardiac arrhythmias, a common complication of Kawasaki disease answer 2 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients with carditis or congestive heart failure, common complications of patients with rheumatic fever answer 3 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients who are post-cardiac catheterization. "I east prepared" implies skills and knowledge that are not directly transferable. Look for the option that is different; in this question, the infant who is post-op pyloromyotomy is the only patient who does not have any cardiac involvement The nurse in the emergency department triage area must decide which of the following children should be examined first by the pediatrician. Which child requires immediate attention? A 3-year-old who fell off his bicycle and has several lower extremity lacerations requiring sutures. A 2-year-old with laryngotracheobronchitis who has wheezing on auscultation and a respiratory rate of 28 breaths per minute. A 6-month-old who fell from the sofa onto a carpeted floor, hitting her head. A 4-year-old with asthma who has diminished wheezing and is very irritable. Diminished wheezing in a child with asthma indicates possible worsening of respiratory obstruction, especially when coupled with irritability, which is a sign of air hunger answer 1 is incorrect because lacerations requiring sutures would not be a priority unless there was arterial hemorrhage answer 2 is incorrect because these symptoms are consistent with a fairly mild case of laryngotracheobronchitis answer 3 is incorrect because this type of fall onto a padded surface does not usually result in severe head trauma. Note the use of the words "immediate attention" in this question, meaning potentially life threatening. Therefore, narrow the options to the two respiratory conditions The RN is supervising a nurse's aide who is caring for a child with a multidrug-resistant respiratory infection. Which action by the aide would be unsafe and would require the nurse's immediate attention? The aide wears a gown and gloves when entering the child's room. The aide removes the gown and gloves before leaving the child's room. The aide leaves the sphygmomanometer, thermometer, and stethoscope in the child's room, out of the child's reach. The aide washes her hands after removing her gloves, and then leaves the child's room to care for another child in the next room. In addition to removing gown and gloves, the aide should wash her hands before leaving the child's room answers 1,3, and 4 are incorrect because these actions arc appropriate and would not require the nurse's immediate attention. Key word: "unsafe." Use a true-or-false approach to rule out the three approaches that are OK The RN assigns an LPN/LVN to care for a child with Hirschsprung's disease; the child's abdomen is grossly distended. The RN directs the LPN/LVN to measure the child's abdominal girth. Which action by the LPN/LVN would require the RN's intervention and further direction? The LPN/LVN: Uses a cloth tape to measure the child's abdominal girth. Leaves the tape in place after measuring the child's abdominal girth. Measures the child's abdominal girth at the umbilicus. Pulls the tape snug, but not tight, around the abdomen when measuring girth. Cloth tape can stretch over time, eventually resulting in inaccurate measurements. The RN should intervene and direct the LPN/LVN to use paper tape instead of cloth tape answers 2,3, and 4 are incorrect because these actions are appropriate and would not require intervention and further direction. Key words: "intervention and further direction," implying that the best answer is the incorrect action A child with a diagnosis of "rule out meningitis" is admitted to the pediatrics unit. The RN assigns this child to an LPN/LVN. Admitting orders include the following: bed rest with vital signs q2h; CBC with chemistry and electrolytes; gentamicin 80 mg IVPB q8h; liquid diet as tolerated; nasopharyngeal culture; and droplet precautions. In what sequence should the RN instruct the LPN/LVN to implement these orders? Put the child to bed and check vitals, take culture, draw blood, start antibiotics, initiate droplet precautions, order diet. Offer fluids, draw blood, take culture, put the child to bed and check vitals, start antibiotics, initiate droplet precautions. Initiate droplet precautions, put child to bed and check vitals, take a culture, start antibiotics, draw blood, order diet. Draw blood, start antibiotics, initiate droplet precautions, take culture, offer fluids, put child to bed and check vitals. The nurse should always initiate infection control measures, such as droplet precautions, before administering any other care, in order to protect the nurse, other health care workers, and other patients and their families answers 1, 2, and 4 are not correct because the nurse is not initiating infection control measures first, but is checking vitals or offering fluids or drawing blood first. Infection control is always a priority of care The nursing student is teaching a newly diagnosed diabetic adolescent about the disease and its treatment. Which statement by the student would require the RN's intervention? When you use the vial of insulin marked 'U80,' it means that there are 80 units of insulin in that vial. Be sure to check in with your doctor right away if you develop a fever or have an infection. You could develop a complication called ketoacidosis. When you are getting ready to give yourself insulin, first draw up the short-acting insulin and then draw up the intermediate-acting insulin. You should check your blood sugar four times a day, just like the MD ordered. The supplies are easily transportable and can go with you wherever you go. U80 means that there are 80 units of insulin per milliliter, not 80 units of insulin in the vial answers 2, 3, and 4 are incorrect because these statements arc true and do not require the RN's intervention. "U" (units) followed by a number always refers to the number of units of insulin per milliliter The RN instructs the aide to give a child with eczema her bath. Which action by the aide would require the RN to provide additional supervision? The aide: Adds bath oil to the water. Bathes the child for 15 to 20 minutes. Provides toys for water play. Applies Lubriderm to the skin immediately after the bath. The child with eczema should be bathed in plain water, with no oils or soaps, to avoid further damage to the skin answers 2, 3, and 4 are incorrect because these actions are appropriate and require no additional supervision. Note the use of the words "require . . . additional supervision" in this question, meaning incorrect, or not OK The nurse is caring for all of the following patients. Which patient should the nurse recognize is at the highest risk for fluid and electrolyte imbalance? Infant with acute gastroenteritis. Toddler with lead poisoning. Preschooler with leukemia. School-age child with multiple trauma. Infants have the greatest percentage of fluid per pound of body weight than any other age group and are at highest risk for fluid and electrolyte imbalance answers 2, 3, and 4 are incorrect because none of the other conditions is at the highest risk for fluid and electrolyte imbalance. It is not an age variable but the condition that is at risk An RN can safely delegate three of the following tasks to an LPN/LVN caring for a child with Down syndrome. Which one task should the RN perform personally and not delegate to an LPN/LVN? Transporting the child to the cardiac catheterization lab. Taking the child's vital signs, including blood pressure. Listening to the child's breath sounds bilaterally. Assisting the child to eat meals and snacks. Diet soda contains aspartame (NutraSweet), which metabolizes into phenylalanine answers 1, 3, and 4 are incorrect because these food items are allowed on a low-phenylalanine diet that this child is undoubtedly on. Products containing aspartame (NutraSweet) should not be given to any patient with PKU. The stem calls for an elimination approach to what is OK to offer and what is not OK The RN should instruct the LPN/LVN or UAP caring for a child with PKU to be sure not to give this child: Green grapes. Diet soda. Cheerios. Cranberry apple juice. This activity, auscultation of breath sounds, involves assessment skills. Patient transport (Answer 1), taking vital signs (Answer 2), and helping with activities of daily living (Answer 4) do not involve assessment and can therefore be safely delegated to an LPN/LVN. Key concept in delegation: patient assessments can be done only by the RN During a routine physical examination, a healthy, well-nourished 16-year-old male tells the nurse that he feels like killing his girlfriend because she broke up with him. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previous history of violence or psychiatric illness. All other findings are within normal limits. The best action for the nurse to take at this time would be to: Regard the comment seriously and notify the teen's primary health care provider and parents. Recall that teenage boys often say things they really do not mean, and ignore the comment. Suggest the teen meet with a counselor to discuss his feelings about the breakup with his girlfriend. Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem. Any threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse answer 2 is incorrect because the nurse should never ignore threatening comments answer 3 is incorrect because simply suggesting a meeting with a counselor at some vague point in time would not be sufficient swer 4 is incorrect because this action is theoretically incorrect. To narrow the choices, note two contradicting options: not OK (1) vs. OK (2). Choose the option in which safety is an issue. Safety is always a priority of care A nurse's aide is working with a group of children in the playroom. Which action by the aide would require the RN to intervene? The aide offers a pacifier to an infant who is NPO. The aide opens a can of Play-Doh and gives it to a toddler. The aide stops a preschooler with terminal cancer from pulling on the braids of another child who is ready to be discharged. The aide tells a school-age child that he is too big to be crying for his parents. No child or patient should be told not to express his or her feelings. Crying when upset is normal and healthy for any patient, regardless of age answers 1, 2, and 3 are incorrect because these actions are age and condition appropriate, and do not require the nurse to intervene. Concept: therapeutic interventions/ communication calls for encouraging patients to express their feelings A nursing student has been assigned to plan the prehospitalization teaching for a group of preschoolers having elective surgery. The preceptor should correct the teaching plan if it included which of the following? Make a list of the things the children could bring from home. Show the children a video describing activities that will take place during their hospital stay. Provide a detailed explanation to the children of what they will experience during preadmission testing. Give the children a tour of the ambulatory surgery unit, Preschoolers, who arc at an age of fears and fantasies, should not be given detailed explanations of treatments answers 1, 2, and 4 are incorrect because these actions are age appropriate and do not require the preceptor to correct the teaching plan. The concept here is an age-appropriate activity. Preschoolers should be given a simple and brief explanation, shortly before the intervention Which of the following tasks could the RN safely delegate to a UAP? Give an oatmeal bath to a 1-year-old with eczema. Monitor the I&O of a comatose 3-year-old with salicylate poisoning. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious multi vehicle accident. Check the IV of a 4-year-old with Kawasaki disease. Bathing a child with eczema can be safely delegated to an aide, who should be competent in performing this basic task answer 2 is incorrect because only an RN can monitor an I&O, which is critical in a case of acute poisoning with an unpredictable outcome answer 3 is incorrect because an RN should be caring for a child with major trauma answer 4 is incorrect because only an RN can make an assessment. Look for non-assessment, predictable outcome, stable condition, noncomplex care A child with severe pain asks for pain medication. The team caring for this child includes an RN, an LPN/LVN, and a UAP. After assessing the child, the RN administers the pain medication. Who should subsequently evaluate the effectiveness of the pain medication? The RN only. The RN and the LPN/LVN. The LPN/LVN and the UAP. All of the members of the team caring for this child. Only the RN should evaluate the efficacy of pain medication or other treatments/medications answers 2,3, and 4 are incorrect because the LPN/LVN and the UAP are not legally responsible for evaluating the efficacy of pain medication. Recall that the concept of delegation sets responsibility for assessment/evaluation with the RN, not other assistive personnel A 9-year-old child with a brain tumor refuses to take chemotherapy. Both parents are present and insist that the RN administer the chemotherapy. The RN should: Administer the medication as ordered. Hold the medication and discuss this as soon as possible with the charge nurse and the MD. Offer distraction and then proceed to put the medication into the child's IV line. Leave the parents and child alone for awhile, to discuss this important issue privately. A 9-year-old child is within the age of reason, and his or her wishes regarding treatment must be considered by the health rare team. The nurse, as part of the team, should consult with other team members before administering chemotherapy that the child refuses answers 1 and 3 are incorrect because the nurse should not administer chemotherapy against the child's wishes answer 4 is incorrect because the family should not make this important decision without the support and input of the health care team. The best option involves the concept of patients' rights: patients have the right to refuse medication or treatment An RN from the obstetrics unit is floated to the pediatrics unit. Which patients could the charge nurse safely assign to this float nurse? A child who has had a nephrectomy for Wilms' tumor. A child receiving IV chelating therapy for lead poisoning. A child with Kawaski disease and cardiac complications. A child who suffered a closed head injury in a 10 ft fall from a tree. The RN floated from the obstetrics unit should be able to safely care for a patient with major abdominal surgery, because this nurse has cared for patients with cesarean births answer 2 is incorrect because the RN floated from the obstetrics unit probably has not cared for patients receiving chemotherapy answer 3 is incorrect because the RN floated from the obstetrics unit probably has limited experience with cardiac problems answer 4 is incorrect because the RN floated from the obstetrics unit probably has limited experience with neurological injuries. Look for the implied experience and skills that are applicable from one clinical area to another A child with diabetes experiences a hypoglycemic episode while hospitalized. The RN instructs the UAP to give the child a glass of orange juice. The RN should then instruct the UAP to: Include this amount of liquid on the child's I&O sheet. Offer the child a choice of Jell-O or pudding. Bring the child several small cups of a variety of juices to keep at the bedside. Provide the child with a snack of peanut butter and crackers. After administering a concentrated sugar to a patient with hypoglycemia, the nurse should be sure the child receives a complex carbohydrate, which will help maintain a steady blood sugar level answer 1 is incorrect because simply adding this amount to the I&O is not sufficient answers 2 and 3 are incorrect because offering more concentrated sweets will likely result in an unstable blood sugar level. When two options are very similar (2, 3), neither option can be correct A 2-year-old patient has had an open reduction for a fractured femur; his current weight is 25 lb 7 oz. He is in skeletal traction, and the physician has ordered meperidine (Demerol) 50 mg IM q6h prn for severe pain and muscle spasms. The nurse should recognize that: This dose of Demerol is excessive for a child of this age and weight. This dose of Demerol is appropriate for a child of this age and weight. 2-year-old children usually do not require pain medication, and this order should be questioned. 4. 2-year-old children usually do not require pain medication, but if the doctor ordered this drug for him, the nurse should give it as ordered. Although the nurse may not know the recommended dose, the nurse should recognize that 50 mg of Demerol is a normal adult dose. This would clearly be unsafe and inappropriate for a 2-year-old answer 2 is incorrect because this is a normal adult dose and is not appropriate answer 3 is incorrect because any patient may require pain medication, regardless of age answer 4 is incorrect because the nurse should never administer medication simply because the doctor ordered it. Narrow the choice to two contradicting options: in this situation, OK (2) vs. not OK (1), meaning it is excessive for a child An LPN/LVN is caring for a child who is postop and complaining of pain; the child asks for pain medication at 5 p.m. The LPN/LVN notes that the last dose was given at 11:30 a.m. The MD's order is for Demerol 25 mg IM q4-6h prn for pain. The RN supervising this LPN/LVN should expect the LPN/LVN to: Administer the Demerol as ordered and then ask the RN to monitor the child for pain relief. Report these findings to the RN. Notify the MD that the child may be developing a dependence on Demerol. Administer the Demerol as ordered, and then chart whether or not pain relief is noted. The LPN/LVN should never give a prn medication unless the RN has completed an assessment of the patient to determine if it is safe and appropriate answers 1 and 4 are incorrect because the LPN/LVN should never give a prn medication unless the RN has completed an assessment of the patient to determine if it is safe and appropriate answer 3 is incorrect because the LPN/LVN should not contact the MD; this is the RN's responsibility. Notice the pattern in the responses: two options give the drug, while two report/notify. Knowing role/responsibilities about assessment, eliminate the options that give the drug. Next, apply the lines of authority concept to arrive at the best answer When administering an IM injection to a young child, the nursing student aspirates before injecting and notices blood in the syringe. The RN should instruct the student to: Inject the drug and then complete an incident report. Withdraw, change needles, and inject the drug in another site. Inject the drug slowly, over a 2-minute interval, and watch for possible adverse reactions. Withdraw the needle one-quarter inch and aspirate again; if no further blood is obtained, inject the medication. Whenever the nurse aspirates blood when pulling back in giving an injection, the nurse must withdraw the needle and change it for another sterile needle. The nurse should then inject the medication in another site answers 1,3, and 4 are incorrect because it is unsafe to inject when the nurse has aspirated blood; there is always the possibility of injecting the drug directly into the bloodstream. Note the pattern in the responses: two options give the injection as is, and two do not. You must identify this as a problem and not OK to give this injection. Next, apply the concept of sterile technique to choose the best option The LPN/LVN is assigned to administer both an aerosol bronchodilator and an aerosol steroid to a child with asthma. The RN should instruct the LPN/LVN to administer: Both inhalers simultaneously. The bronchodilator first and the steroid second. The steroid first and the bronchodilator second. Neither; the RN should question these orders with the MD. By giving the bronchodilator first, this will help the air passages to open more fully. This enables the steroid to reach as deeply as possible into the bronchi, for maximum benefit to the patient answers 1 and 3 are incorrect because the bronchodilator should be given first answer 4 is incorrect because these medications can be given close to one another. Remember: bronchodilator first, steroid second The RN instructs the UAP to collect a routine urine specimen on an infant. Which action by the UAP would require the nurse's intervention and further direction? The UAP washes her hands and puts on gloves. The UAP cleanses and dries the infant's genital area. The UAP applies the bag directly to the infant's skin, with the urethral meatus in the center of the opening. The UAP leaves the bag in place until it is full of urine. Leaving the bag in place until it is full may cause tissue damage, as well as increase the likelihood of the bag pulling off and the specimen being lost answers 1,2, and 3 are incorrect because these actions are appropriate and would not require the nurses' intervention and further direction. The question is asking which action is not OK, not safe. The RN assigns an LPN/LVN to care for a child who just had a spinal tap to rule out meningitis. Which observation(s), if reported by the LPN/LVN within the first hour after the tap, should the RN follow up on? The child refuses fluids after the tap. The child denies having a headache. The child is lying flat in bed and states that he does not have a headache. The child is resting quietly and vital signs are within normal limits. After a spinal tap, patients should be encouraged to drink fluids to replace the circulating cerebrospinal fluid (CSF) and prevent a spinal headache answers 2, 3, and 4 are incorrect because these findings are within normal limits and require no follow-up. Intervention is usually required for abnormal findings, not normal findings The parents of a 12-year-old child call the clinic early one morning because they are concerned about their son. They report that he is refusing to go to school because he has a severe headache; he vomited once and the parents say that there has been a virus going around his class. The best advice for the clinic nurse to offer them over the phone should be: Bring your son into the clinic as soon as you can. Offer your son Tylenol or ibuprofen, and then drive him to school about an hour later. Give your son Tylenol or ibuprofen every 4 hours and monitor for fever; keep him home today. These symptoms are most likely due to the virus and should improve within 24 hours. Be sure he gets plenty of rest and fluids. These symptoms may indicate a potentially life-threatening infection such as bacterial meningitis, and the child should be evaluated promptly and thoroughly answers 2 and 3 are incorrect because they would only cover up the symptoms answer 4 is incorrect because this statement can not be safely made on the basis of the information the parents have offered without first seeing the child. When two answers (2,3) are very similar, neither answer can be correct The RN caring for a child with acute lymphocytic leukemia is called to the phone to speak with a caller who claims to be the child's aunt and godmother and who lives in another country. The woman is clearly upset, and tearfully asks the nurse whether the child's leukemia has relapsed. From report, the nurse is aware that the child is out of remission and that chemotherapy was started within the past hour. The nurse should tell the caller: Yes, unfortunately the child just began chemotherapy again. I just came on duty and have not had a chance to review the child's chart yet. I'm sorry, but I cannot give out that information over the phone. You really need to speak with the doctor about the child's condition and treatment. Confidentiality precludes the nurse from giving this kind of information over the phone answer 1 is incorrect because this is a breach of confidentiality answer 2 is incorrect because it defers addressing the issue of confidentiality answer 4 is incorrect because it disregards the caller's obvious distress. After directly answering the woman's question, the nurse might consider this as a possible follow-up statement. The concept of confidentiality and nurse-appropriate role points to the best answer A patient is in a withdrawn catatonic state and exhibits waxy flexibility. During the initial phase of hospitalization for this patient, the nurse's first priority is to: Watch for edema and cyanosis of the extremities. Encourage the patient to discuss concerns that led to the catatonic state. Provide a warm, nurturing relationship, with therapeutic use of touch. Identify the predisposing factors in the illness. Circulation may be severely impaired in a patient with waxy flexibility who tends to remain motionless for hours unless moved. Answer 2 is not the first priority. "Touch" is not used in this stage, as in Answer 3. Answer 4 is incorrect because the patient is mute and also because intellectual discussion of predisposing factors ignores the feelings of the patient. Note the key words: "first priority." An elderly client who has dementia related to cerebral arteriosclerosis says to the nurse, "I'm going to the university to day to be their guest lecturer on aerodynamics." Which response by the nurse would be most therapeutic? Do you know that you are in the hospital now? Are you saying that you would like to be asked to give a lecture at the university? How about watching a movie on television instead? It's more important that you don't tire yourself out. The best of four poor choices here is an attempt to understand what the client means. The other choices are not helpful. Answers 3 and 4 switch the focus and ignore the client's statement; Answer 1 is too brusque an attempt to bring the client back to reality. Asking for clarification is a therapeutic communication technique. Which nursing approach would be best for a client with symptoms of severe depression? Allow the client time for quiet thought; remain silent. Ask the client to join the nurse and the other clients in the TV lounge. State that the nurse would like to go with the client for a short walk around the outside grounds, and assist the client with his or her coat. Give the client a choice of recreational activities. This will reduce the isolation and withdrawal while at the same time not putting the burden of decision making on the client. The client needs a structured routine that is simple. The client may not be able to handle close proximity to more than one person at this point, as in Answer 2. Answer 1 incorrectly allows the client to remain isolated; Answer 4 is incorrect because the client needs a structured routine until he or she can make decisions for himself or herself. Review theory on depression. Activity is a therapeutic intervention, on a 1:1 basis, and without requiring an answer or verbal interaction. When assessing clients who are exhibiting a depressed episode and those who are exhibiting a manic episode of bipolar mood disorders, which characteristic common to both episodes of the disorder is the nurse likely to note? Suicidal tendency. Underlying hostility. Delusions. Flight of ideas. In the depressed episode, anger is turned inward; in the manic, it is noted in sarcasm, demanding behavior, and angry outbursts. Answers 3 and 4 occur in the manic episode. Answer 1 is a particular problem in the depressed phase. Remember point of theory: depression may be anger turned inward as opposed to expressed outwardly (as in manic behavior). A patient who is overweight is referred by the physician to the nurse for diet counseling. What action would the nurse take? Develop a weight control plan, together with the patient, that will allow gradual weight loss. Ask the patient to describe his or her eating patterns. Support the patient's interests in other activities. Put the patient on a diet with very limited number of calories so he or she will have an immediate weight loss. The nurse should formulate a weight control plan, in cooperation with the patient, that allows for a gradual weight loss, not immediate loss as in Answer 4. Answers 2 and 3 are incorporated into Answer 1. When three options are good, choose the one that covers them all. Also look at two contradictory options: "gradual" vs. "immediate" weight loss. Choose the more realistic option ("gradual"). A patient begins having auditory hallucinations. When the nurse approaches, the patient whispers, "Did you hear that terrible man? He is scary!" Which would be the best response for the nurse to make initially? What is he saying? I didn't hear anything. What scary things is he saying? Who is he? Do you know him? I didn't hear a man's voice, but you look scared. This is a reality-based response, as well as one that acknowledges the patient's nonverbal reaction. The other choices are not the best because Answers 1 and 3 focus on "voice," which reinforces the hallucination, and no doubt is placed; in Answer 2 doubt is placed, but the focus is on "voice" and not on patient's feelings. Note the key word "initially," which includes reality orientation and patient's feelings. After seeing a number of doctors for nonspecific complaints of chest pains, with no conclusive findings of organic disease, a client is referred to a local mental health center. The client has read extensively about coronary disease and talks continuously about the symptoms in great detail. Which approach by the nurse would be best when meeting this client for the first time? Allow the client to describe the physical problems to become familiar with them. Comment on a neutral topic instead of using the usual conversation opener of "How are you today?" Give the client a simple but direct explanation of the physiological basis for the symptoms. Let the client know that the nurse is familiar with the psychogenic problems and guide the discussion to other areas. It shows acceptance by listening to the client's initial account of the physical problems. Neither a superficial focus nor a technical explanation of physical problems (Answers 2 and 3) conveys acceptance of the client as a person; Answer 4 is too abrupt for an initial response. Look at the verbs: "allow," "comment," "give," "let (the patient know)." Choose the one that most conveys acceptance. A 35-year-old married clerk had surgery for ulcerative colitis 3 days ago. The physical symptoms have abated, but he continues to complain angrily and to be demanding of the nursing staff. He makes numerous requests, such as to open or close the windows and to bring him fresh water. The nurse needs to understand that this behavior might be saying: You aren't doing your job. I am alone and helpless and need to depend on you to take care of me when I need you. Everyone needs attention. I'm going to get even with you for thinking I'm a crank by making you work. Characteristic underlying needs in somatoform disorders are dependency, attention, and the need for security through trust. Answers 1 and 4 are incorrect because the patient's complaints are not aimed at blaming others or at seeking vengeance but at expressing dependency needs and seeking security. Answer 3 is inappropriate because the patient is expressing his or her own need for attention; the patient is not speaking for everyone. Apply the process of elimination. Eliminate the two hostile options (1,4); next eliminate the global "everyone." The nurse is aware that the main function confabulation serves in clients, especially those with dementia, is to: Impress others. Protect their self-esteem. Control others by distance maneuvers. Maintain a sense of humor. Because confabulation is a coping mechanism, the best choice is the one that defines one of the main functions of coping mechanismsto protect self-esteem. Answers 1 and 3 are incorrect because they focus on others, not on self. Answer 4 is completely irrelevant. Choose the response that focuses on the patients, after eliminating two options that focus on others (1, 3). It's a "patient focus vs. others" type of tip. A 19-year-old patient is brought to the emergency department because she slashed her wrists. What is the nurse's first concern? Stabilization of physical condition. Determination of antecedent, causal factors relevant to the wrist slashing. Reduction of anxiety. Obtaining a detailed nursing history. Deal first with the lifesaving situation. Answers 2 and 3 are incorrect because they are done following stabilization of physical condition. Answer 4 is incorrect because it is not a necessary lifesaving concern. Note key words "first concern," which is a priority on Maslow's hierarchy of human needs (e.g., physiological needs). A patient who is agitated begins to shout insults and threats at others, and starts demolishing the recreation room. What is the best response or action by the nurse? Firmly set limits on the behavior. Allow the patient to continue, because the patient is seeking to express herself or himself. Tell the patient he or she is trying to intimidate other clients. Let the patient know that he or she does not need to express anger at the nurse by demolishing the recreation room. The nurse needs to set limits to ensure the safety of the patient and others. Answer 2 is incorrect because the patient may hurt herself or himself or others. Answers 3 and 4 are incorrect because they are interpretations that may or may not be correct, and they do not control the unsafe behavior. Look at two options that are contradictory ("allow" and "limits"). Because the main concern is safety when a patient is agitated, select Answer 1. Avoid interpretive statements (3,4). A second-grade girl starts at a new school, and the child's grades suffer while focusing on adjusting to new peers. The father severely reprimands the child and forces the child to study after school rather than play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development? A love relationship with the father. Close relationships with peers. Heterosexual relationships. A dependency relationship with the father. In second grade a person needs to form close relation ships with peer Answer 1 needs to occur earlier than second grade or later in early teen years. Answer 3 occurs later. Answer 4 is incorrect because the father's actions make the child dependent on him rather than on peers. Know normal age-appropriate growth and development. The nurse is interviewing a teenage patient with acting-out behaviors. The teenager complains that no one will let him "do his own thing," and sits glaring at the nurse. What is the nurse's best response? I know you are angry, but how does being angry help? Stop being angry and tell me what is wrong. I think you are angry because you feel you don't need any help. We have to meet because your parents are concerned about you. This tells the teenager the nurse heard his statement about "not doing his own thing" and thinks he is angry. Answer 1 is incorrect because this states the nurse knows he is angry. Answer 2 is incorrect because an angry person can not stop being angry on command. Answer 4 is incorrect because focusing on the parents puts the nurse on their side. Choose a therapeutic communication response that focuses on the teenage patient's feelings (not "we," "your parents" as in Answer 4). A patient looks at a mirror and cries out, "I look like a bird. My face is no longer me." Which would be the best response by the nurse? Which bird? That must be a distressing experience; your face doesn't look different to me. Maybe it was the light at that particular time. Would you like to use another mirror? What makes you think that your face looks like a bird? This acknowledges the experience and points out reality as the nurse sees it. Answers 1, 3, and 4 do not focus on the patient or attempt to explore feelings. An effective response to hallucinatory behavior is to support the feeling aspect ("distressing") while also pointing out reality. A patient with ulcerative colitis and the patient's family are ready to make discharge plans jointly with the staff. Which assessment will have the greatest bearing on the patient's rehabilitation course? The amount of emotional support the family gives the patient. The spouse's interest in and ability to take care of the postoperative dietary needs. The family expectations of the patient to resume his or her role in the home. The spouse's understanding that the course of the illness may have exacerbations and remissions. Emotional support is a key need. Answer 2 does not focus on emotional support. Answer 3, role expectation, in itself has no bearing; emotional support of role would. Answer 4 would help the spouse and his or her own emotional reaction but would not help the patient. Best answer focuses on emotional support for the patient. Eliminate the three other options because they focus on the spouse or family. A 10-year-old child diagnosed with acute leukemia, terminal stage, asks the nurse one morning: "I am going to die, aren't I?" What would be the most appropriate response by the nurse? No, you're not. You are getting the latest treatment available and yon have a very good doctor. Your white count was better yesterday. We are all going to die sometime. What did the doctor tell you? I don't know. You have a serious illness. Do you have feelings that you want to talk about now? An honest, direct answer that focuses on feelings is the best approach. Answers 1, 2, and 3 stop any further exploration of the client's feelings. Choose the answer that helps explore feelings. Eliminate the other three options that close off communication and focus on facts, not feelings. For a patient with a diagnosis of a somatoform disorder, which would be the appropriate initial nursing goal? Help the patient learn how to live with the functional organic disturbance without using the symptoms to control others. Assist the patient in developing new and varied interests outside of himself or herself at which he or she can be successful. Accept the patient as a person who is sick and needs help. Help the patient see how he or she uses the illness to avoid looking at or dealing with problems. Showing acceptance and gaining trust and confidence are usually the key initial nursing goals. You need to show acceptance before helping (Answers 1 and 4) or assisting (Answer 2). Focus on the phrase "initial nursing goal," which is acceptance. Note the lead verb: accept before help or assist. An acutely ill patient hospitalized with metastatic lung carcinoma begs for a pass to attend her son's high school graduation in a city 100 miles from the hospital. "If only I could do this one thing, then I'll be ready to die," the patient says. The nurse identifies this behavior as an example of: Being unrealistic and denying the degree of illness. Using bargaining as a reaction to death and dying. Being manipulative to get the patient's way. Being unaware of the diagnosis. Refer to Elisabeth Kbler-Ross's emotional stages of death and dying. She is being neither unrealistic (Answer 1), manipulative (Answer 3), nor unaware of her diagnosis (Answer 4). Select the response that typifies a common grief reaction ("bargaining"); eliminate the three responses that have a negative tone ("deny," "manipulative," "unaware"). A patient who is overweight says to the nurse, "My therapist told me I eat because I didn't get enough love from my mother. What does the therapist mean?" What is the best response for the nurse to offer? Tell me what you think the therapist means. We are here to deal with your diet, not with your psychological problems. You need to ask your therapist. What do you think is the connection between your not getting enough love and your overeating? This reply asks for information that the nurse can use. If the patient understands the statement, the nurse can support the therapist when focusing on connections between food, love, and mother. If the patient does not understand the statement, the nurse can help get clarification from the therapist. Answer 2 alienates the client, and the nurse loses the chance for collaboration with the therapist. Answer 3 shuts the patient off. Answer 4 is incorrect because it is asked before the nurse is sure the patient understands the therapist's statement. Choose a therapeutic communication response that helps the patient give the nurse feedback (on patient understanding of therapist statement). An elderly patient who is hard of hearing repeats, over and over again, the same story of the patient's family coming "out West" in a covered wagon. Which interpretation by the nurse would not demonstrate understanding of this behavior? The patient has better recall for past events than for recent ones. The patient enjoys reliving the pleasurable aspects of life, because the present and future are bleak. Repeating stories is one way of interacting, to compensate for a two-way conversation that is difficult for the patient to sustain. The patient wants to impress others. Redundancy is not meant to impress others but is aimed at pleasure gained through focus on the past and need to control the conversation when memory or hearing deficit is present. Answers 1, 2, and 3 would demonstrate understanding of this behavior. Focus on the key phrase "not demonstrate understanding"; use a true-or-false approach. A nursing carp plan for a hospitalized hyperactive client in a manic episode must include: Involvement in a group activity and encouragement to talk. Attention to adequate food and fluid intake, Protection against suicide. Permissive acceptance of bizarre behavior. During a manic episode, the client may he too busy to eat and sleep. Answers 1 and 3 are more appropriate for a depressive episode; Answer 4 is more appropriate for schizophrenia with bizarre behavior. Clients in manic episode exhibit hyperactive behavior. Match characteristic behaviors with other main diagnostic categories: depression with Answers 1 and 3 and schizophrenia with Answer 4. The nurse finds an elderly patient with Alzheimer's in the hallway at 4:00 a.m., trying to open the door to the fire escape. Which response by the nurse would probably indicate the most accurate assessment of the situation? You look confused. Would you like to sit down and talk with me? That door leads to the fire escape. Why do you want to go outside now? This is the fire escape door. Are you looking for the bathroom? Something seems to be bothering you. Let's go back to your room and talk about it. Nocturnal urination is a most common need, complicated by disorientation related to the patient's age, disorder, and unfamiliar environment at night. To sit down (Answer 1) or to go back to the patient's room and talk (Answer 4) does not take care of the possible problem, the need to urinate. Asking a person "why" questions (Answer 2) is not helpful and is too literal a response to the behavior. Confusion (Alzheimer's) and age-typical physiological need (nocturia) call for a response that is reality orientation and environmental redirection (to the location of the bathroom). Since the death of her baby, a woman has lost weight, will not eat, spends most of her time immobile, and speaks only in monosyllabic responses. She pays little attention to her appearance. One afternoon, this patient comes to lunch with her hair combed and traces of lipstick. What could the nurse say to reinforce this change of behavior? What happened? You combed your hair! This is the first time I've seen you look so good. You must be feeling better. You look much better. I see that your hair is combed and you have lipstick on. A simple acknowledgment of what the nurse sees is the best response. Answer 3 makes an assumption that the patient feels better if she looks better. Answers 1 and 2 can be taken as a put-down. Eliminate put-downs and assumptions. Keep it simple (KIS) and simply acknowledge what the nurse observes. While the nurse is interviewing a teenage patient, the patient says, "I suppose you have to tell my parents everything." What would be the best response by the nurse? What are you going to tell me that is so secret that I can't tell your parents? If you tell me you are going to do something to hurt yourself I will have to tell your parents, but I will tell you first before I tell them. Everything you tell me is confidential. I will not tell your parents anything. Everything you tell me I will need to tell your parents. They have a right to know. Confidentiality cannot be guaranteed if there is a danger to the patient or to others. Answer 1 is incorrect because it is a sarcastic response and denies that the patient has serious problems. Answer 3 contradicts Answer 2. Answer 4 is incorrect because parents do not have the right to know the content of therapy sessions except in the circumstances described in Answer 2. Eliminate two options with the global "everything" and one option that can be seen as a put-down. In paranoid disorder, the part of the personality that is weak is called the: Id. Ego. Superego. Not me. A diagnosis of a paranoid disorder implies weak ego development. Answers 1,3, and 4 are incorrect because a client with a paranoid disorder might have strong id, super ego, and "not me" components. Focus on the word "weak" in the stem. A key consideration in planning the general care of clients with dementia is that: They be protected from suicide attempts. Their capacity for physical activity is diminished. Team effort be aimed at increasing their independence. The staff be sympathetic when clients mention their failing abilities. An important principle to remember here is that a program of care should not increase physiological losses by over taxing the client's physical capacities. It is important to remember that suicide is the main concern of depression and not a key concern of dementia, as in Answer 1. Empathy rather than sympathy (Answer 4) is a helpful behavior. Answer 3, increasing independence, is not realistic; maintaining it is. Apply the process of elimination. Eliminate Answer 4 because "sympathy" is not therapeutic; eliminate the unrealistic response in Answer 3; eliminate Answer 1 because it applies to depression, not to general care in dementia. A college student was doing exceptionally well and was complimented by her chemistry professor, who arranged for her to become his lab assistant and to do advanced research. Although very thorough in her work, when given constructive criticism this student becomes angry and stalks out of the lab for a few hours. The most plausible theoretical explanation is that the student: Knows she is right. Thinks the professor is jealous of her. Needs to feel and know that she is perfect. Feels anxiety as a result of a threat to her security and self-image. This is the all-inclusive answer. Answers 1,2, and 3 may be part of Answer 4. Choose the "umbrella" answer (i.e., most inclusive) when all four options are correct. One therapeutic nursing attitude is to be accepting and permissive. To convey this attitude most therapeutically, the nurse might: Wait for a client to initiate contact. Let the client make decisions. Ignore undesirable behavior. Meet the client at his or her level of functioning. If a particular client is nonverbal, for example, the nurse should not expect that client to function at a verbal level until ready. In Answer 1, if the nurse waits for a client who is withdrawn to make contact, it may not be helpful. In Answer 2, a client who is ambivalent may need assistance in making decisions. In Answer 3, the client's undesirable behavior may be adversely affecting others. Apply a reasoning "What if.." approach: "What if" a patient will not initiate, can't make decisions, and undesirable behavior can't be ignored?. The basic goal of nursing in a mental health setting is to: Plan activity programs for clients. Maintain a therapeutic environment. Understand various types of family therapy and psychological tests and how to interpret them. Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness. This is the most neutral answer by process of elimination. Answer 1 is mainly the function of a recreational-occupational therapist, although nurses participate. Answer 3 is usually filled by psychologists and social workers, and Answer 4 is carried out primarily by psychologists or statisticians, although nurses are involved. "Maintenance of a therapeutic environment" fits more readily into a nursing role by virtue of the number of hours per day a nurse spends with the clients on a unit, in comparison with the number spent by other professionals. Keep it simple (KIS) response; a mental health setting should keep a therapeutic environment. Which nursing intervention is inappropriate with a person who is expressing anger? Stating observations of the expressed anger Assisting the person to describe the feelings. Helping the person find out what preceded the anger. Helping the person refrain from expressing anger verbally. A person needs to be allowed to express anger appropriately. Answers 1, 2, and 3 are incorrect choices here because they are things the nurse assists a person to do when intervening in anger. Key word: "inappropriate. The client tells the nurse about the client's parents' impending divorce. The client said, "I couldn't believe that he was going to leave us for someone else." Which would be best for the nurse to reply? Was your mother expecting this to happen? Yes, go on. Did you cry? I can understand how you must feel. Offering a broad opening by giving a general lead is most therapeutic to elicit further description of the client's reaction and to clarify feelings, which were vaguely stated. Answer 1 is a switch of focus from the client to the mother. Answer 3 is nontherapeutic because a question that can be answered by yes or no often closes off further exploration. Answer 4 could be a helpful intervention but is premature acknowledgment before feelings have been elaborated. Choose the most therapeutic communication response: giving a broad opening, with a general lead to clarify feelings. A crisis intervention nurse meets with a young patient who was admitted after attempting suicide by slashing the wrists. The nurse's initial goal at this time is to: Determine the precipitating event, determine how many people are involved in the incident, and determine how angry the patient is. Determine if the patient has an immediate support system, determine what the people in the support system think of the patient cutting the wrists, and determine how angry the patient is. Determine the precipitating event, determine if the patient has an immediate support system, and assess the likelihood of immediate recurrence of the suicidal act. Assess the likelihood of immediate recurrence of the suicidal act. It incorporates all information a crisis intervention nurse needs immediately. Answers 1 and 2 are incorrect because the nurse does not need to know about other people's involvement at this time. Answer 4 is incorrect because it is not as complete as Answer 3. Key words: "initial goal. A client states, "The nofas are coming." In response to this neologism, it would be best for the nurse to: Divert the client's attention to an aspect of reality. State that what the client is saying has not been understood and then divert attention to something that is reality bound. Acknowledge that the word has some special meaning for the client. Try to interpret what the client means. It is important to acknowledge a statement, even if it is not understood. Answer 1 is not a direct response; Answer 2 leaves out the importance of the meaning of the neologism to the client; and Answer 4 is less valid and important than acknowledgment of the meaning to the client. Look at the verbs: "divert," "state," "acknowledge," "interpret." Select "acknowledge" as the first response. Which nursing approach is important in depression? Providing motor outlets for aggressive, hostile feelings. Protecting against harm to others. Reducing interpersonal contacts. Deemphasizing preoccupation with elimination, nourishment, and sleep. It is important to externalize the anger away from self. Answer 2 is incorrect because usually the client is turning anger inward, toward the self. Answer 3 increases the client's sense of isolation. The needs in Answer 4 should be emphasized, not deemphasized, because the depressed client often has somatic delusions. Apply a commonly accepted point of theory about depression: anger turned inward that needs to be externalized. One evening the nurse sees a client in the dayroom without any clothes, shouting vulgarities and dancing wildly about the room while other clients are watching TV. the best initial response by the nurse at this time would be: Let's sit down with the others and watch TV; I'll put this blanket over you to keep you warm. We do not allow this behavior in the hospital. It is embarrassing the other clients. Please put your clothes on. Come put your clothes on. I will help you. It is a matter-of-fact statement that is direct, while offering assistance and setting limits on inappropriate behavior. The other choices are not useful because Answer 1 reinforces inappropriate social behavior; Answer 2 sets limits but does not state a positive expectation for the client to follow; and Answer 3 neither offers assistance nor sets limits, which the patient needs. Pay attention to the phrase "best initial response." The nurse discovers a client crouched in a corner, looking pale and frightened, and holding a gushing wrist wound. A razor is nearby on the floor. What should the nurse do first? Sit down on the floor, next to the client, and in a quiet, reassuring tone, say, "You seem frightened. Can I help?" Ask the aide to watch the client and run to get the doctor. Apply pressure on the wrist, saying to the client, "You are hurt. I will help you." Go back down the hall to get the emergency cart. Take care of the bleeding (physical aspects of care) first. In Answers 1 and 2 the client could suffer extensive blood loss if the nurse focuses on feelings at this point or leaves the client without first attempting to control the bleeding. In Answer 4, the client is left alone, bleeding, frightened, and with a razor still at the side. Be aware that the stem asks for first action. Which characteristic should the nurse recognize as common in a person engaged in gradual self-destructive behavior (such as in obesity, drug addiction, and smoking)? Acceptance of the death wish. Denial of possibility of death. Ability to control own behavior. Ignorance of the consequences of own behavior. Persons engaged in self-destructive behavior other than active suicide behavior fantasize that they can control their behavior and deny the likelihood of death as a result. Thus Answers 1,3, and 4 are incorrect. Know theory about gradual self-destructive behaviors and eliminate the three that are theoretically incorrect (1,3,4). Look at two options that are opposites (acceptance and denial) and choose a most common defense mechanism (denial). A divorced woman learns that her ex-husband has died. Her reaction is stunned silence, followed by anger that he left no insurance money for their young children. The nurse should understand that: The woman is experiencing a normal bereavement reaction. To explain the woman's reaction, the nurse needs more information about the relationship and breakup. The children and the injustice done to them by their father's death are the woman's main concern. The woman is not reacting normally to the news. Shock and anger are commonly the primary initial reactions. Answer 2 is irrelevant. Answer 3 is a literal, concrete interpretation of the patient's reaction, not aimed at the possible latent feelings. Answer 4 is incorrect because it contradicts the correct answer, Answer 1. Look at two contradictory options (normal vs. not normal); review normal grief reactions and choose "normal. What will the nurse most commonly note in the clinical picture of dementia? Memory loss for events in the distant past. Quarrelsome behavior directly related to the extent of lack of blood supply to the brain. Increased resistance to change. Insight into one's situation, its probable causes, and its logical consequences. One of the main needs experienced by most clients with dementia is the need for most things to be the same. The other choices are wrong for the following reasons: there has been no demonstrable evidence of relationship between any behavior symptom and the extent or severity of pathophysiological condition (Answer 2); intellectual blunting usually occurs, which interferes with ability to deal with insight and abstract thoughts (Answer 4); and memory loss is for recent events and names, not those in the distant past, as in Answer 1. Key words: "most commonly. A man is hospitalized following a car accident in which his wife died, and he is unable to attend the funeral due to his severe chest injuries. What would the nurse consider in forecasting this surviving spouse's potential for difficulty with grief resolution? Feelings of anger toward the hospital staff for keeping him hospitalized during the funeral. Feelings of anger toward himself for having been injured but not killed in the accident. His inability to participate in the cultural rituals of grief, wherein the reality of his wife's death is emphasized. His preoccupation with his own physical distress at this time. One way to enhance the development of unresolved grief is not to participate in activities that demonstrate death. Answers 1, 2, and 4 may occur, but they are not the best predictors of grief resolution difficulties. Apply theory about unresolved grief (which may be related to lack of culturally sanctioned rituals for "letting go"). A patient who is depressed says, "I don't cry because my wife can't bear it." The nurse needs to be aware that this is an example of: Suppression. Undoing. Repression. Rationalization. Rationalization is the process of constructing plausible reasons for one's responses. Answer 1, suppression, is the intentional exclusion of material from consciousness. Answer 2, undoing, is an act that partially negates a previous one. Answer 3, repression, is the involuntary exclusion of painful or conflicting thoughts or feelings from awareness. Review definitions with clinical application of defense mechanisms. When interacting with clients who have autistic thinking and speaking patterns, what is likely to pose the greatest difficulty for the nurse? Showing acceptance for their incomprehensible acts and verbalizations. Ignoring their bizarre behavior. Speaking in a way that client can understand. Determining which of the clients' needs are being met by their autistic expressions. Decoding symbolic, autistic expressions calls for skill and sensitivity in understanding latent messages. Answer 1 is not a good choice, because showing "acceptance" is a basic, initial nursing goal that does not require a complexity of skills. Answer 2 points out a nontherapeutic nursing action, which is best not to use at all. Answer 3 implies that the nurse use short sentences with clear, concise, unambiguous meaning; this can be accomplished with practice. Answers 1 and 3 must be accomplished before Answer 4 is possible. Greatest difficulty is the key phrase to keep in mind. A patient refuses to eat meals in the hospital, stating that the food is poisoned. The nurse is aware that the patient is expressing an example of: Hallucination. Illusion. Delusion. Negativism. This is a false belief developed in response to an emotional need. In Answer 1, the situation is not a perceptual disorder. In Answer 2, the situation is not a misperception. In Answer 4, although the patient refuses meals, the reason for this is a false belief (delusion). Know the difference between a false belief, a misinterpretation, and misperception. An adolescent has a history of truancy from school, running away from home, and "borrowing" other people's things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand that psychodynamically, this behavior may be largely attributed to a developmental defect related to the: Id. Ego. Superego. Oedipal complex. This shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego. Answer 1 is incorrect, because the id is strong. These disorders are not characterized by a weak ego, as in Answer 2, whereas schizophrenia is. Answer 4 is of relevance in sexual-identity difficulties rather than in personality disorders. Sociopathic behavior and weak superego can be matched. Key word: "defect. What is the nurse likely to note in a patient being admitted for alcohol withdrawal? Perceptual disorders. Impending coma. Recent alcohol intake. Depression with mutism. Frightening visual hallucinations are especially common. Answer 2 is incorrect because coma is usually not an immediate consequence of alcohol withdrawal. Answer 3 is incorrect because the diagnosis is withdrawal from alcohol, not alcohol intoxication (intake). Answer 4 is incorrect because the patient will be agitated and rambling in conversation, not mute and depressed. Key words: "likely," "on admission," and "withdrawal. A patient says he must wash his hands from 9:00 to 9:45 a.m. each day and therefore cannot attend 9:00 a.m. group therapy sessions. Which concept does the nursing staff need to keep in mind in planning nursing interventions for this patient? Fears and tensions are often expressed in disguised form through symbolic processes. Unmet needs are discharged through ritualistic behavior. Ritualistic behavior makes others uncomfortable. Depression underlies ritualistic behavior. Anxiety is generated by group therapy at 9 A.M. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy. Answer 2 is incorrect because tension, not unmet needs, is discharged through ritualistic behavior. Answer 3 may be true, but it is not essential to planning care. Answer 4 is incorrect, because depression is not characteristic of ritualism. Apply theory about ritualistic behavior (also called obsessive-compulsive disorder, which is an anxiety disorder). "Fears" and "tensions" are similar to "anxiety. To formulate an effective care plan for a client with a somatoform disorder, the nurse needs to have an understanding of which related psychodynamic principle? The major fundamental mechanism is regression. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention, and love. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings. The client's symptoms are imaginary and the suffering is faked. Somatoform disorders provide a way of coping with conflicts. Answer 1 is incorrect because conversion, not regression, is the major coping mechanism. Answer 2 is incorrect because if a possible cause is identified and treatment relieves the discomfort, the client often develops another symptom. Frequently, clients do not want to be cured of their symptoms because they need the symptoms to control the behavior of others or because they do not know how else to get attention. In Answer 4, the converse is true: the symptoms are real, not imagined or faked. When in doubt as to the most theoretically correct answer, choose the option that has "feelings" in it. In evaluating a patient who has somatoform symptoms, the nurse is aware that the patient will probably show the most improvement when he or she: Accepts the fact that the physical symptoms have an emotional component. Finds more satisfying ways of expressing feelings through verbalization. Becomes involved in group activities and focuses less on the symptoms. Understands that the current way of reacting to stress is not healthy. All the other choices (1,3,4) are correct but can be dove tailed into Answer 2. Choose the "umbrella" answer that encompasses the other three choices. An important part of the nursing care for a client with dementia would be: Minimizing regression. Correcting memory loss. Rehabilitating toward independent functioning. Preventing further deterioration. Use of regression as a coping response can be minimized. Memory loss is usually permanent, not correctable; thus Answer 2 is wrong. However, disorientation attributed to loss of memory can be minimized. Clients usually become more dependent in the course of illness and deteriorate progressively. Thus Answers 3 and 4 arc incorrect. Know what can and cannot be ameliorated. Whereas the nurse cannot stop the pathological course of Alzheimer's disease (i.e., memory loss impermanent; deterioration is progressive and rehabilitation is not possible), use of a coping mechanism (regression) can be minimized. In explaining the goal of therapy in crisis intervention to a new colleague, the nurse states that the goal is to: Restructure the personality. Remove specific symptoms. Remove anxiety. Resolve immediate problems. The major goal of crisis intervention is to resolve immediate problems. Answer 1 is incorrect because restructuring personality is the goal of psychoanalytic therapy. Answers 2 and 3 are incorrect because they are goals of brief psychotherapy, and although they may occur in the resolution of immediate problems, they are not the goal. Note the similarity between the word "crisis" in the stem and "immediate" in the correct option. The steps in therapeutic nursing intervention with an angry client would be to describe the situation, then: Discuss alternative solutions, decide on several, try them out, and evaluate their effectiveness. Focus on one solution, try it out, and evaluate its effectiveness. Outline to the client exactly what to do about the anger. Discuss alternative solutions, decide on one, use it, evaluate its effectiveness, and continue repeating the process until the client is satisfied. It provides the complete steps. Answer 1 is incorrect because of the phrase "decide on several"; it should be one solution at a time. Answer 2 is incorrect because it does not include "discuss alternative solutions." Answer 3 is incorrect because it does not describe a requested series of steps and because giving a person one answer is untherapeutic. The best answer meets the condition of the stem: a series of steps in the therapeutic process. Answer 2 would be also a good choice, but it is incomplete (misses one step). Eliminate Answer 1 because it is an overload (i.e., several solutions); and eliminate Answer 3 because it is dictatorial, not a discussion. Therefore, first focus on the two options that have "discuss" and choose "one solution" at a time. On a routine physical, a woman learns she has a lump in her breast. It is found to be malignant, and a modified mastectomy is performed. Immediately following the surgery, what behaviors could the nurse expect this patient to display? Signs of grief reaction. Signs of deep depression. Relief that the operation is over. Denial of the possibility of carcinoma. It is most likely that grief would be expressed because of object loss. Answer 2 is incorrect because deep depression, if it occurs, would be the result of lack of resolution of grief over object loss. Answer 3 is incorrect because relief is not part of the grief process. Answer 4 is incorrect because the question asks for the client's immediate response. Denial of carcinoma, if it occurs, would probably occur later. Note the word "immediately" following the surgery. A 19-year-old patient's over compliance with his parents' expectations for his behavior could result in: Lack of development of a separate identity. Confusion of his sex role. Successful development of a separate identity. Identification of a weak superego. Overcompliance leads to lack of development of self-identity, one of the major problems in schizophrenic disorders. Answer 2 is incorrect because there are no substantiating data. Answer 3 is incorrect because it contradicts the correct statement in Answer 1. Answer 4 is incorrect because the patient probably has a strong superego due to an implied "should" system (over compliance with parents' expectations of behavior). Look at two contradictory options: "lack of separate identity" vs. "a separate identity. A doctor asks the nurse to activate a patient who hears voices and is withdrawn and negativistic. What would be the nurse's best approach? Give the patient a long explanation of the benefits of activity. Tell the patient that the nurse needs a partner for an activity. Demand that the patient join a group activity. Mention that the "voices" would want the patient to participate. The nurse helps to activate by doing something with the patient. Answer 1 is incorrect because the patient will not hear a long explanation. Answer 3 is incorrect because demanding will not work; the patient cannot join in unless you are with the patient (as in Answer 2). Answer 4 is incorrect because you should not produce psychosis to motivate a person. Look at key words in the options and eliminate the three worst: "long explanation"; "demand"; "voices want the patient. When an experiment in the laboratory goes wrong, a researcher complains of a plot against her, and accuses the lab assistants of sending signals about her to each other. The nurse would determine that this behavior is related lo: Delusions of grandeur. Illusion. Ideas of reference. Echolalia. The meaning of "ideas of reference" is that all that goes on is somehow connected to a person. Answer 1 is incorrect because delusions of grandeur mean a person has an exalted opinion of self. Answer 2 is incorrect because illusion is a false perceptual experience occurring in response to a stimulus. Answer 4 is incorrect because echolalia is a person's automatic repetition of what is said. You can apply the correct term if you understand what the terms mean. A teenager with acting-out behaviors says to the nurse, "I want you to go tell the teacher I am sick and I am to be allowed to do what I want." The nurse determines that this statement best represents: Insight. Manipulation. Dependency. Trust. Manipulation is the attempt to control the behavior of others to achieve one's own goals. Answer 1, insight, is understanding and using understanding to correct one's behavior. Answers 3 and 4 are incorrect because although the client may be trying to con the nurse into believing he or she needs the nurse to do something for him or her and the client trusts the nurse, the real purpose of the request is manipulation. Review the concept of manipulation. Eliminate three options that have no relationship to "acting out" (insight, dependency, trust). A 52-year-old patient who appears lucid learns that after surgery, he will wake up in the recovery room without his thick glasses and hearing aid. He immediately states that without these he will be confused and upset. The nurse determines that the patient is trying to say that he: Has periods of confusion and may have a psychiatric problem. Is psychologically dependent on the hearing aid and glasses. Needs the hearing aid and glasses to correctly perceive what is going on around him, and misperception will cause confusion. Needs the hearing aid and glasses because he wants to be sure people are taking proper care of him. A person with limited hearing and sight becomes confused and disturbed. Answers 1 and 4 are unwarranted assumptions. Answer 2 is incorrect because the patient's situation is not psychological dependency but actual sensory need. Choose the most reasonable explanation and avoid making assumptions (1,4). A patient relates angrily to the nurse that his wife says he is selfish. Which would be the most helpful response by the nurse? That's just her opinion. I don't think you're that selfish. Everybody is a little bit selfish. You sound angrytell me more about what went on. It is important to pick up on a feeling tone and encourage exploration of the feelings and the situation. Answer 1 stops exploration of the patient's feeling. Answers 2 and 3 shift the focus away from feelings to content of selfishness. Focus on feelings and encourage elaboration, with an open-ended statement ("tell me more about.."). When a client has dementia, it is most important that the nurse plan the daily activities to: Be highly structured. Be changed each day to meet the client's needs for variety. Be simplified as much as possible to avoid problems with decision making. Provide many opportunities for making choices to stimulate the client's involvement and interest. Clients with dementia feel more secure when they can count on their environment being the same, predictable, and consistent in detail from day to day (hence, structured) to compensate for feelings of loss of the familiar in terms of body functions, social environment, and so on. Answers 2 and 4 imply change, not routine. Answer 3, although correct, is not the most important. Two options are correct (1,3). When the activities are structured (the best response), they are usually also simplified and avoid decision-making problems. This is a "telescope" answer, in which a broader option subsumes a narrower one. A woman tells the nurse that she refuses to eat her husband's cooking because she thinks he is poisoning her. The nurse is aware that this behavior is related to: Delusion of persecution. Ideas of reference. Illusion. Hallucination. The patient has ideas that someone (her husband) is out to kill her. Answer 2 is incorrect because the problem is beyond just an "idea of reference" (she fears bodily harm). Answer 3 is incorrect because illusion is a false perceptual experience occurring in response to a stimulus. Answer 4 is incorrect because a hallucination is a sensory experience triggered by a person's inner needs, functioning independently of stimulation from the environment. Know your terminology to spot the only correct answer. The crisis nurse explains to a colleague that the focus of treatment in crisis intervention is on the: Present and on restoration to the usual level of functioning. Past and on freeing the unconscious. Past in relation to the present. Present and on the repression of unconscious drives. To resolve immediate problems, focus on a person's ability to cope and usual level of functioning. Answer 2 is incorrect because it is a psychoanalytic focus. Answers 3 and \ are incorrect because they are the focus of brief psychotherapy. Crisis focuses on the present and restoration of here-and-now coping. A patient in the postoperative period following surgery for ulcerative colitis suddenly becomes angry with another patient who is monopolizing the group therapy meeting. Which interpretation of this noted change in behavior would indicate that the nurse understands the dynamics of this patient's somatoform disorder? The patient is intolerant of others. The patient has strong competitive drives. The patient has his or her own ideas of how the group members should act. The patient is repressing fewer feelings. One coping mechanism often seen in somatoform disorders is repression. As the patient is better able to handle the anxiety connected with underlying feelings, the need for repression lessens. Answers 1,2, and 3 may be the content of the patient's feelings, but they do not explain the dynamics, the reason the patient is expressing more feelings. Note the key word: "dynamics." Separate content from dynamics to choose the best answer. A client has a somatoform disorder, paralysis of the arm. It would not be helpful for the nurse to use logic and reason to divert this client's attention from this physical state because: The client is not in contact with reality and thus is unable to "hear" or understand the nurse. The client may need the symptoms to handle feelings of guilt or aggression. The nature of the client's particular illness makes the client suspicious of all medical personnel. Paralysis of the arm has become a habitual response to stress. This disorder is an attempt to cope with stress and is a better choice than Answer 4, which may be true but is a tangential and irrelevant reason. Answer 1 is not correct because the client is aware of reality but may not understand the cause for the somatoform disorder. Answer 3 is more relevant in a paranoid reaction. Look for the statements that correctly explain somatoform disorders (2,4); eliminate Answer 4 because it is incorporated in Answer 2. While communicating with a patient who is withdrawn, what would be important for the nurse to do at first? Remain silent and not encourage the patient to talk. Talk with the patient as one would to a normal person. Allow the patient to do all the talking. Use simple, concrete language in speaking to the patient. Patients with withdrawn behavior in schizophrenic disorders tend to think in concrete terms. Therefore, use of simple language enables them to grasp meaning. Answer 1 is incorrect because if the nurse remains silent the patient will remain silent. Answer 2 is incorrect because if the nurse is not concrete the patient might have trouble understanding some terms in normal conversation. Answer 3 is incorrect because the patient has difficulty talking. KIS means keep it simplei.e., "simple .. language. The nurse bases a plan of care on the knowledge that persons engaged in gradual self-destructive behavior: Believe they can stop this behavior at any time. Have decreased anxiety when they stop the behavior. Believe the behavior controls them. Believe the behavior, in some manner, is "good" for them. These persons have not faced up to the idea that they are controlled by their behavior, and this relieves their anxiety. Contrary to Answer 2, persons have increased anxiety if they stop the behavior. Answer 3 is also incorrect because they fantasize that they control their behavior. Answer 4 is incorrect because these persons know the behavior is not "good" for them. Eliminate the three options that are opposite of correct points of theory. When a patient with symptoms of severe depression says to the nurse, "I can't talk; I have nothing to say," and continues being silent, what should the nurse do? Say, "All right. You don't have to talk. Let's play cards, instead." Explain that talking is an important sign of getting well and that the patient is expected to do so. Be silent until the patient speaks again. Say, "It may be difficult for you to speak at this time; perhaps you can do so at another time." Meet the patient at her or his level of functioning, and provide support and encouragement for a higher level in the near future. Answer 1 implies that the nurse agrees that the patient has nothing to say. Answer 2 conveys no empathy or understanding. Answer 3 is incorrect because silence reinforces silence and a sense of isolation. The best answer acknowledges feelings and is supportive, without reinforcing the silence. When talking with a client who is exhibiting a manic episode with flight of ideas, the nurse primarily needs to: Speak loudly and rapidly to keep the client's attention, because the client is easily distracted. Focus on the feelings conveyed rather than the thoughts expressed. Encourage the client to complete one thought at a time. Allow the client to talk freely. Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged. Flight of ideas should be curtailed; thus Answer 4 is incorrect. The client may not be able to control the internal stimuli to focus on one idea at a time as in Answer 3. A louder and more rapid tone by the nurse may only increase the external stimuli for the client, making Answer 1 incorrect. Choose the answer that focuses on feelings. A patient says to the nurse, "I was going to kill myself last night." What is the best initial response by the nurse? Say nothing. Wait for the patient's next comment. What were you going to do this time? Have you felt this way before? You seem upset. I am going to be here with you; perhaps you will want to talk about it. The patient needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse's presence. The patient may interpret the nurse's silence as discomfort in talking about suicidal feelings and thoughts (Answer 1). Answer 2 focuses on facts too swiftly without providing an opportunity for the patient to express feelings. Also, Answer 2 would be most appropriate in crisis intervention when the patient is, first admitted, not the next morning. Answer 3 moves away from focus on here-and-now to focus on the past. Choose the answer that focuses on acknowledging feelings. Which feeling is the nurse likely to identify as antecedent of self-destructive behavior? Omnipotence. Grandiosity. Low self-esteem. Self-satisfaction. When feelings of low self-esteem are prevalent, self-destructive behavior reaches its peak. Hence, Answers 1,2, and 4 are incorrect. Low self-esteem is the option that is different from the three other options (omnipotence, grandiosity, self-satisfaction). Resolution of grief related to death is likely to be complicated when: There are ambivalent feelings for the deceased. The death was due to a chronic illness. It is the first loss to be experienced. There was little emotional dependency on the deceased. Love-hate feelings take longer to resolve. Reactions to loss tend to be cumulative in effect, in that the more loss experienced in the past, the greater the reaction the next time; thus Answer 3 is wrong. Reactivation of feelings connected with previous losses by the current loss accounts for the increased intensity of the reaction. Sudden, unexpected death, rather than death due to a chronic illness, as in Answer 2, is harder to resolve, and strong, not little, emotional dependency (as in Answer 4) also complicates grief resolution. Apply your knowledge about grief theory to choose the only correct answer. Which behavior might the nurse expect from a patient with congestive heart failure who is in the grief stage of developing awareness of the loss of a spouse? Crying, anger, or both. Appearing dazed and repeatedly saying, "No, it can't be." Preoccupation with thoughts of how ideal the marriage had been. Responding with a brief complaint about the patient's own physical pain. These behaviors are correct according to Lindemann's and Engle's grief stages. Hence, incorrect are Answer 2 ("shock" stage), Answer 3 ("idealization" stage), and Answer 4 ("resolving the loss" stage). Review stages of grief to choose the correct stage. What feeling tone is the nurse most likely to see the client demonstrate during major depression with psychotic features? Suspicion. Agitation. Loneliness. Worthlessness. Feelings of worthlessness or low self-esteem are the underlying problem in depression. Answers 1,2, and 3 may occur but are not most apt. Note key phrase: "most likely to see. When a client's behavior is considered abnormal, the nurse first needs to: Ignore the client. Serve as a role model. Point out the client's disturbed behavior. Focus on the feelings communicated by the client's behavior. Focusing on feelings is usually the best choice. Ignoring the client is rarely an acceptable intervention (Answer 1). Pointing out disturbed behavior and role modeling by the nurse are valid, but not as first interventions (Answers 2 and 3). Key words: "first need. A hospitalized patient cannot find his slippers and accuses other patients and staff of stealing them. The most therapeutic approach is to: Listen without reinforcing the patient's belief. Logically point out that the patient is jumping to conclusions. Inject humor to defuse the intensity. Divert the patient's attention. Listening is probably the most effective response of the four choices. A key consideration in interacting with patients who are suspicious is to avoid the use of logic and argument; thus Answer 2 is incorrect. Humor usually intensifies the anger and suspicion; thus Answer 3 is incorrect. Changing the topic, as in Answer 4, may serve to reinforce the patient's belief in the guilt of others. Choose the term that involves the least action and does not reinforce suspicious behavior. In interacting with a patient with an antisocial personality disorder, what would be the most therapeutic approach? Reinforce the patient's self-concept. Gratify the patient's inner needs. Give the patient opportunities to test reality. Provide external controls. Personality disorders stem from a weak superego, implying a lack of adequate controls. Answer 1 is not relevant, as the patient's self-identity is not a focus here. Answer 2 is incorrect because the patient typically gratifies his or her own inner needs; this is part of the difficulty with a strong id, and requires external controls as in Answer 4. Answer 3 is incorrect because the patient is not psychotic, but has a personality disorder for which reality testing is not impaired. The patient is aware of reality. Test taking tipApply knowledge about antisocial behavior to select the only correct answer, and to eliminate the three that are theoretically incorrect. To relate therapeutically with a patient who is dependent on alcohol, it is important that the nurse base his or her care on the understanding that alcohol dependence: Is hereditary. Is due to lack of willpower and true remorse. Results in always breaking promises. Cannot be cured. Arrest of the disease is possible through abstinence, not through change in psychophysiological response to alcohol. Answers 1,2, and 3 are stereotyped statements, not generally or universally accepted. Choose the least controversial belief: that alcohol dependence cannot be cured. Eliminate the option that has "always"; eliminate the option that is a clich (Answer 2); it has not been universally accepted that alcohol dependency is hereditary. A patient uses repetitive hand washing. To help the patient use less maladaptive means of handling stress, the nurse could: Provide varied activities on the unit, because change in routine can break this ritualistic pattern. Give the patient unit assignments that do not require perfection. Tell the patient of changes in routine at the last minute to avoid buildup of anxiety. Provide an activity in which positive accomplishment can occur so the patient can gain recognition. The opposite of what is stated in the first three choices is true. The patient seems to do best when routine activities are set up and anxiety-provoking changes are avoided (Answer 1); perfection-type activities bring satisfaction (e.g., cleaning and straightening a linen closet) (Answer 2); and the patient knows ahead of time about changes in routine (Answer 3). By knowing, understanding, and applying theory about dynamics of ritualistic behavior, you can eliminate three options that are theoretically inaccurate. You can also make an educated guess and choose as the best option the answer that includes the phrase "positive accomplishment can occur. The most common coping mechanisms used in somatoform disorders are: Repression and symbolism. Sublimation and regression. Substitution and displacement. Reaction formation and rationalization. The original source of conflict, pain, or guilt is repressed (pushed out of awareness), only to surface in a symbolic way. Answers 2,3, and 4 are only partially correct: in somatoform disorders, regression is common, not sublimation; displacement is common, not substitution; reaction formation is common, not rationalization. To serve as the best answer, all parts must be correct, not just partially correct. Review coping mechanisms as they relate to somatoform disorders. A patient who has been hospitalized with ulcerative colitis asks the doctor about the prognosis. The patient becomes alternately depressed and agitated when hearing of the impending discharge. Which nursing approach would be best at this time? You are much better than when you first were hospitalized. You have to decide whether you need to be hospitalized longer or whether you are ready to go home. You seem to have concerns about going home. What is it about going home that bothers you? You seem sad about going home. Would you like to talk about it? It reflects the patient's underlying concerns in the most open-ended manner. Answer 1 is incorrect because the nurse cannot say how the patient is feeling; this assumes here that the patient is better, which is inappropriate. Answer 4 focuses on only one aspect: sadness. What about the agitation the patient also expresses? Answer 3 is not incorrect, but it is also not the best choice because it asks a direct question when a simple acknowledgment (as in Answer 2) would be better initially. KIS (Keep It Simple); a simple acknowledgment is the most open-ended communication approach. Eliminate Answers 3 and 4 because they require the patient to answer. Eliminate Answer 1 because it is an overload. It is important for the nurse to be aware that the mental health of an aged client is most directly influenced by: The attitude of relatives in providing for the client's needs. Societal factors such as role change, loss of loved ones, and loss of physical energy. The client's level of education and economic situation. The attitudes the client has toward life circumstances. Although all the other choices (1,2,3) are valid and important, Answer 4 encompasses them all and is therefore the most comprehensive answer. Test taking tipWhen all four options are correct, choose the "umbrella" answer that includes them all. In crisis intervention therapy, the nurse plans her or his goals based on the principle that crises: May go on indefinitely. Seldom occur in normal people's lives. Usually are resolved in 4-6 weeks. Are related to deep, underlying problems. Part of the definition of a crisis is a time span of 4-6 weeks. Answer 1 is incorrect because by definition, crises do not continue indefinitely. Answer 2 is incorrect because all people have crises, and having crises does not determine abnormality. Answer 4 is incorrect because although crises may be related to deep, underlying problems, one of the principles of crisis intervention therapy is to deal with the immediate situation, not the underlying problem. By definition, crisis are short term. Look at two contradictory options: "indefinitely" vs. short term ("4-6 weeks"). The nurse can determine that the expression of hostility is appropriate and useful when the: Energy from anger is used to accomplish what needs to be done. Expression intimidates others. Degree of hostility is less than the provocation. Expression of anger dissipates the energy. This is the proper use of anger. Answer 2 is incorrect because although anger can be used to intimidate others, that use creates interpersonal problems. Answer 3 is incorrect because in order for hostility to be a helpful communication mechanism, the degree of hostility must be appropriate to the provocation. Answer 4 is incorrect because this expression of anger does not produce positive accomplishment. The best answer is usually the most understandable, with a positive tone, and free of jargon. Answer 2 has a negative tone ("intimidate others"); Answers 3 and 4 are confusing as to meaning. Two days after a mastectomy, a woman is crying and saying, "My husband won't love me anymore." The nurse is aware that this statement might stem from: The woman's deep insecurity about her marriage. Preexisting marital disharmony. The woman's concerns about her body and a resultant change in her beliefs about her own self-worth. A momentary fear about her husband's fidelity. A change in body image has made the patient feel unloved and unworthy of love. Answers 1,2, and 4 are incorrect because there are no supporting data. Eliminate the three options in which there is lack of information in the stem to support data about problems in the marriage. The best option centers on the patient and her self-concept. The nurse establishes a nurse-client relationship with a patient with a schizophrenic disorder. One of the goals is to help the patient develop a separate self-identity. One way to do this is to: Call the patient by a "pet" name frequently. Use "you" and "I" rather than "we." Correct the patient's opinions. Encourage "should" responses. Use of "you" and "1" forces the patient to acknowledge separate identities. Answer 1 is incorrect because "pet" names are usually not a person's choice. The patient needs to be called by his or her real name. Answer 3 is incorrect because the patient has no identity it he or she cannot have his or her own opinions. Answer 4 is incorrect because "should" responses imply others' ideas, not the patient's. The best answer ("you" and "I") reflects the stem: separate self-identity. Keep it simple (KIS) by selecting the obvious answer. A patient is diagnosed as having a paranoid disorder. What implication might this have for the nurse? Let the patient talk about her or his suspicions without correcting misinformation. Avoid talking to other nurses when the patient can see them but cannot hear what is being said. Placate the patient by agreeing with what he or she says. Argue with the patient about his or her ideas. A patient with paranoid disorder is suspicious, so a nurse must make every effort not to engage in behavior the patient can misinterpret. Answers 1 and 3 are incorrect because a nurse should give correct information about what the patient says and not placate him or her (the patient will sense the falseness). Answer 4 is incorrect because arguing just solidifies the patient's ideas. In a neutral voice, the nurse should give correct information. Review interventions with paranoid behavior to choose a response that minimizes distortions and avoids reinforcing the pathology. A teenage patient says to the nurse, "I want you to go tell the teacher I am sick and I am to be allowed to do what I want." What is the nurse's best response? Certainly. You are sick and need some relaxation of rules in the classroom. I am glad you recognize you are sick. No, you are expected to follow the rules of the classroom. All teachers are too strict. I agree some rules need to be relaxed. This response stops the manipulation and suggests the patient is responsible for his or her own behaviors. Answers 1, 2, and 4 are incorrect because they indicate that the nurse has been conned and manipulated. First, recognize manipulative behavior; next, rule out the three options that may play into this. A 50-year-old patient says he needs his glasses and hearing aid with him in the recovery room after surgery, or he will be upset and confused. What is the nurse's best response? You won't need your glasses or hearing aid. The nurses will take care of you. I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room. I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know. Do you get upset and confused often? The patient will be easier to care for if he has his hearing aid and glasses. In Answer 1, the nurse is denying the patient his right to the full information of his senses. Answer 3 is incorrect because the nurse has the responsibility to change rules for clearly therapeutic reasons. Answer 4 does not respond to the patient's needs. Choose the option that starts with "I understand" and in which the nurse takes on a patient advocacy role. A mother talks about her daughter, who is mentally retarded: "She's really an inspiration to me, do you know what I mean?" Which would be the most appropriate initial comment by the nurse? What makes her an inspiration? It seems to be important to you to find something positive about her. No, explain more about what you mean. Tell me more about her. An appropriate direct response to a "you know what I mean" comment is to say you do not automatically know what is meant. Answers 1,2, and 4 are not the best response because they shift the focus from the client's experience to the characteristics of the other person. First, choose the answer that directly relates to the mother's question; then, seek clarification. At the first therapy session with a patient who recently attempted suicide, what does the crisis nurse need to do? Discourage discussion of the suicide attempt. Encourage the patient to focus on feelings about how badly the patient was treated as a child. Encourage the patient to discuss the suicide attempt in detail. Help the patient see how the suicide attempt hurt others. The patient needs to be aware of his or her actions and the possible ramifications of those actions. Answer 1 is incorrect because the patient needs to discuss the actions. Answer 2 is incorrect because the purpose of crisis intervention is to deal with the present problem and situation, not the past. Answer 4 is incorrect because the focus must be on the patient, not on others. First note the two options that are similar ("encourage") and one that is the opposite ("discourage"). Next, compare the difference between the two "encourage" options: one focuses on the past ("as a child") and the other on the here-and-now (recent suicide attempt). Choose the latter option. A mother says to the nurse, "When my baby had asthma 5 years ago, I thought he was going to die." What would be most appropriate for the nurse to say? What made you think that he was going to die? What did you do? You thought he was dying? What were some of your feelings at that time? Attempts to focus on encouraging the client to describe feelings are important. Answers 1 and 2 ask for facts rather than focusing on feelings, and Answer 3 is an example of reflectinga therapeutic response, but in this case it only reflects a thought, not a feeling. Choose the feelings-oriented option. In preparing the nursing care plan for an elderly man, the most common basic need that must be met is: Sexual outlet and security. Unconditional acceptance by others of his impairments and deficits. Preservation of self-esteem. Socialization. Self-esteem is the most basic psychological need at any age, especially so for the elderly. Answers 1,2, and 4, although also important, are not the most basic needs. When you see an option that has "self-esteem," go for it! One effective way for a nurse to start an interaction with a client who is silent is to: Tell the client something about himself or herself and hope that the client does the same. Remain silent, waiting for the client to bring up a topic. Bring up a controversial topic to elicit the client's response. Introduce a neutral topic, giving the client a broad opening. This is the least threatening. Answer 2 is incorrect because the nurse needs to intervene into a pattern of silence. It is not therapeutic for the focus to be on the nurse, as in Answers 1 and 3, and bringing up a controversial topic (such as religion or politics) usually results in an exchange of opinions and arguments. The words "neutral" and "broad opening" in Answer 4 lead you to the best answer. What would be the most realistic statement a nurse could make about a patient's prognosis after a course of necessary treatment for ulcerative colitis? The symptoms will recur. The ulcerative lesions will heal, but under stress the same symptoms will reappear. It is not possible to prognosticate the future course. Ongoing psychotherapy is essential for the patient to be free of symptoms. This answer is the best choice because the other choices (1,2,4) seem too certain for a disorder that, although it has a pattern, can be altered if and when the patient adopts different outlets for expressing emotions. Choose the most plausible, tentative response here rather than the three definitive ones ("will," "essential"). What might be the most therapeutic response the nurse could make to a student who begins crying on hearing that he or she failed an exam? You'll make it next time. Failing an exam is an upsetting thing to happen. How close were you to passing? It won't seem so important 5 years from now. This response picks up a "here-and-now" underlying feeling tone. Answers 1 and 4 focus on "there-and-then" rather than "here-and-now" feelings and events, and Answer 3 is irrelevant because the focus is on a fact rather than a feeling. Focus on feelings. Eliminate two options with clichs (1,4) and the option that avoids feelings by asking a factual question. Which adaptive behavior by a client with somatoform disorders might indicate to the nurse the greatest improvement in the client's condition? The client recognizes that the behavior is unreasonable. The client agrees to go to occupational therapy and recreational therapy every day. The symptoms are replaced by expressions of hostility. The client is verbalizing feelings instead of demonstrating them by pathological body languages. Expressing feelings in general through verbalization is a desired outcome. This answer also incorporates a specific feeling in Answer 3. Agreement to attend activities (Answer 2) does not indicate the greatest improvement. The client already recognizes that the behavior is irrational but cannot understand the cause or banish the behavior by will, as in Answer 1. When two answers could be correct, choose the one that incorporates both. A client tells the nurse that he has something he wants to say but does not want the nurse to tell anyone else. The nurse should: Agree not to "tell." Refuse to agree to this. Say nothing, allowing him to go on. Let him know that the nurse cannot promise this. Information that is given to the nurse that may interfere with the client's recovery must be related to other team members. The other choices are not the best response because Answer 1 is withholding information from other staff members who are also responsible for care and may interfere with recovery needs; Answer 2 is a refusal that may stop the interactiona negotiation is needed; and Answer 3 does not provide a client with the clear feedback needed to work through conflict. The best answer calls for knowledge about the concept of confidentiality. Which is an example of limit setting as an effective nursing intervention in ritualistic hand-washing behavior? I don't want you to wash your hands so often anymore. If you continue to wash your hands so frequently, the skin on your hands will break down. You may wash your hands before the group therapy meeting if you wish, but not during group therapy. The doctor wrote an order that you are to stop washing your hands so often. This is the best example of setting limits on the behavior. Answers 1 and 4 may be closely linked to nontherapeutic use of power. Answer 2 is more of an example of a punishment approach. You can readily eliminate the three negative options (nurse power in Answer 1; threatening sounding in Answer 2; MD power in Answer 4). Which nursing intervention is effective when clients are severely anxious? Encourage group participation. Give detailed instructions before treatment procedures. Impart information succinctly and concretely. Increase opportunities for decision making. Brief and specific information can be processed during severe anxiety. In severe anxiety, the person cannot respond to the social environment (as in Answer 1); giving detailed information results in overload, because the client cannot retain and recall data (as in Answer 2). Only directive information that is brief and specific is effective when the client cannot focus on what is happening. Decision making needs to be postponed until the person is less anxious; hence, Answer 4 is wrong. The severely anxious person needs to have "KISS" communicationKeep It Simple and Succinct. A nursing care plan for a patient with a history of alcohol abuse and dependency must incorporate which physical consequence? Cardiac arrhythmia. Convulsive disorder. Psychomotor hyperactivity. Cirrhosis of the liver. The liver is affected by both the direct effect of alcohol and nutritional deficiencies associated with alcohol abuse and dependence. Answers 1,2, and 3 are areas not usually affected by alcohol abuse and dependence. Review physiological consequences of alcohol abuse. When a client tells the nurse that he or she cannot sleep at night because of fear of dying, what would be the best initial response? Don't worry, you won't die. You're just here for some tests. Why are you afraid of dying? Try to sleep. You need the rest before tomorrow's test. It must be frightening for you to feel that way. Tell me more about it. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings. The other choices are not the best response because Answer 1 is false reassurance that does not allay feelings; Answer 2 is asking a "why" question, which is confrontative and may increase anxiety; and Answer 3 gives advice, which stops exploration of underlying feelings. The best answer focuses on feelings. Review and eliminate examples of nontherapeutic communication. A new nurse is assigned to take clients for an outing. A patient with an antisocial disorder approaches the nurse and says, "I like you. I'm glad you'll be the one to take us out. My doctor told me that I can go too." Which initial response by the nurse is best? Since I am new here and not familiar with unit routine, I will go check with the staff and be back. It's a beautiful day, and I'm glad that yon have ground privileges now. When did the doctor tell you that? You seem pleased. This response aims to prevent use of manipulative patterns. In Answers 2,3, and 4, the nurse needs to seek validation, and these responses indicate acceptance without validation. The team approach for consistent reinforcement of rules is needed when interacting with patients who display manipulative behavior. Which common physiological reaction occurring in response to anxiety is the nurse likely to note? Clammy hands and increased perspiration. Palpitations and pupillary constriction. Diarrhea and vomiting. Pupillary dilation and retention of feces and urine. Answer 1 is the best choice because these are typical symptoms/responses to anxiety. Other common reactions are pupillary dilation, not constriction (Answer 2); diarrhea, not constipation (Answer 4). Vomiting is not typical of an anxiety response (Answer 3). Review physiological manifestations of anxiety. Clients with paranoid behavior use projection. The nurse is aware that this mechanism is chiefly a way to: Provoke anger in others. Control delusional thought. Handle their own unacceptable feelings. Manipulate others. This response refers to the definition of projection as a coping mechanism (attributing one's own unacceptable thoughts, feelings, and behaviors to another). Answers 1,2, and 4 are incorrect because they have nothing to do with the coping mechanism of projection. Coping mechanisms in general function in the service of "self"that is, they protect the ego and preserve self-esteem in an effort to cope with anxiety; the focus is not on others, as in Answers 1 and 4. Symptoms of projection do in fact express delusional thought rather than control it, contrary to Answer 2. Select the option that has "feelings. Which most characteristic behavior of a panic response is the nurse likely to note? Goal-directed behavior aimed at a "flight" from apparent threat. Automatic behavior with poor judgment. A severity of reaction that is not related to the severity of the threat to self-esteem. A delayed reaction in perceiving the danger. In panic, a person is highly suggestible and follows "herd instinct" rather than exercising independent judgment and goal-directed problem solving (Answer 1). Answer 3 is incorrect because the severity of the reaction is related to the severity of the threat. The more severe the perceived threat (actual or imaginary), the more intense the reaction to the danger, and not delayed as in Answer 4. Apply knowledge about panic reaction. At limes, a client seems preoccupied with her own thoughts as she grins, giggles, grimaces, and frowns. Although she is 23 years old, her behavior seems childish and regressed. She is unkempt, voids on the floor, disrobes, and openly masturbates. The main nursing care at this time should be directed toward: Improving the client's social conduct to meet hospital standards. Controlling the narcissistic impulses. Finding out why the client is behaving this way. Showing acceptance of the client. The primary initial focus of the nurse-client relationship is in showing the client, through acceptance, that it is the client one is concerned about, not the symptoms. Answers 1 and 2 are incorrect because the focus of initial nursing care is on the client, not on meeting hospital standards or controlling impulses. Answer 3 is incorrect because it is an attempt to analyze the whys of behavior, which is not an appropriate basic nursing intervention and not an initial aspect of care. The key word is "acceptance," a basic tenet of the nurse-patient relationship. The nurse is aware that the two major types of precipitating factors in anxiety are: Fear of disapproval and shame. Conflicts involving avoidance and pain. Threats to one's biological integrity and threats to one's self-system. A person's poor health and poor financial condition. This is the most inclusive answer. Answers 1, 2, and 4 are all incorporated into Answer 3. When all answers are correct, choose the "umbrella" answer that covers them all. After a patient with major depression visits with the spouse, the spouse reports that it was a stressful time. In an interview, the patient says, "We had a marvelous visit." The nurse is aware that this is an example of: Compensation. Denial. Symbolism. Identification. Denial is the act of avoiding disagreeable realities by ignoring them. Answer 1 is incorrect because compensation is the process by which a person makes up for a deficiency in self-image by emphasizing an asset. Answer 3, symbolism, is the use of one mental image to represent another. Answer 4, identification, is the process of taking on another person's attribute. Knowledge of coping mechanisms is necessary to select the only correct answer. Review definitions and examples of the most common coping mechanisms. Psychomotor manifestations of anxiety that a nurse may observe include: Decreased activity. Increased activity. Increased lability of emotions. Decreased lability of emotions. Research shows that increased activity is a psychomotor manifestation of anxiety; therefore, Answer 1 is wrong. Answers 3 and 4 are incorrect because emotion is not a psychomotor manifestation. Note the similarity between the word "psychomotor" in the stem and the word "activity" in Answers 1 and 2. Next decide on "increased activity" by applying theory about anxiety. A patient whose significant other recently died shows signs of grief resolution when he or she: Wants to enter into another relationship soon. Talks of both the positive and negative aspects of their relationship. Makes up for deficiencies in the relationship, saying, "Things would have been better if we had only had more time." Expresses anger toward the deceased. When the mourner can pass through the idealization stage and be more realistic about the positive and negative aspects of the loss, resolution of grief is beginning. Answers 3 and 4 occur in earlier stages of grief. Answer 1 could be a sign of denial of grieving, an initial grief reaction. Because all of the answers could be acceptable, you need to review the stages of grief to identify the best answer in relation to a time sequence. The other three options relate to earlier stages. The nurse needs to know that anxiety may increase intellectual functioning because anxiety may: Increase the perceptual field. Increase ability to concentrate. Decrease the perceptual field. Decrease random activity. Research shows that anxiety decreases the perceptual field; therefore, Answer 1 is incorrect. Research also shows that anxiety decreases the ability to concentrate and increases random activity; therefore, Answers 1,2, and 4 are incorrect. Note the two contradictory options: "increase perceptual field" vs. "decrease perceptual field." Next, apply knowledge about anxiety to select the theoretically correct answer. Answers 2 and 4 are theoretically incorrect. In planning patient care, a nurse needs to know that self-destructive behavior may be interpreted as the: Directing of hostile feelings toward self. Directing of hostile feelings toward others. Directing of hostile feelings toward an internalized love object. Internalization of the fear of death. This is correct by Freudian theory. Answers 1,2, and 4 are incorrect because they are incomplete. The correct answer directly stems from a particular theoretical viewpointFreudian, which you will need to review. Based on knowledge of Erikson's stages of growth and development, the nurse determines that the task of old age is primarily concerned with: Ego integrity versus despair. Autonomy versus shame and doubt. Trust versus mistrust. Industry versus inferiority. This is correct according to Erickson. Answer 2 relates to toddler; Answer 3, to infancy; Answer 4, to latency period in childhood. Review and apply your knowledge of the age-related stages, which will lead to the only correct answer. The nurse must assess for high risk of suicide when a patient's behavior suggests: Major depression with melancholia features. Schizophrenic disorders. Bipolar mood disorder, manic episode. Psychological factors affecting physical condition. Another name for major depression is depression with psychotic features. Suicide risk is a part of all depressions. Answers 2,3, and 4 are incorrect because these diagnoses alone do not indicate suicide risk as does the diagnosis of depression. Depression is the most common direct risk factor for suicide. In working with clients who are depressed, the nurse must know that depression may stem from: A sense of loss actual, imaginary, or impending. Revived memories of a painful childhood. A confused sexual identity. An unresolved oedipal conflict. Toss is most basic to the development of depression. Answers 2,3, and 4 are not essential to development of depression. When in doubt, choose the least controversial, more general answer ("a sense of loss") rather than pinpointing specific causal factors (e.g., "painful childhood," "confused sexual identity," "unresolved oedipal conflict"). When working with a person who is anxious, what is the overall goal of nursing intervention? Remove anxiety. Develop the person's awareness of anxiety. Protect the person from anxiety. Develop the person's capacity to tolerate mild anxiety and to use it constructively. Some anxiety is necessary to learn. Answer 2 is incorrect because it is incomplete. Answers 1 and 3 are incorrect because anxiety is necessary for learning and growth. When two answers seem right, choose the answer that incorporates the other (i.e., capacity to tolerate anxiety would also mean developing awareness of anxiety). In discussions between parents and adolescents about their relationship, a desired outcome is that adolescents benefit because they will be able to: See themselves as the victims. View their parents and themselves realistically. Enlist the therapist's aid as an ally against their parents. See their parents as victims. Part of maturing is learning to view one's parents and oneself realistically. Answers 1,3, and 4 are incorrect because they represent the misinformation that creates problems between individuals. The key word in the correct option is "realistically. The main nursing goal with clients with schizophrenic disorders is to: Set limits on their bizarre behavior. Establish a trusting, nonthreatening, reality-based relationship. Quickly establish a warm, close relationship to counteract their aloofness. Protect them from self-destructive impulses. A permissive atmosphere is the key, as well as a slowly evolving relationship (not quickly evolving, as in Answer 3) with room for distance. Self-destruction is not a persistent problem requiring major focus for concern, as in Answer 4. Answer 1 is not the best response because "acceptance" of bizarre behavior is more important than setting limits. Note the key words in the correct answer: "trusting, nonthreatening, reality-based relationship. A patient is placed in isolation for seclusion due to agitated behavior. The nurse knows it is essential that: Restraints be applied. All the furniture be removed from the isolation room. A staff member have frequent contacts with the patient. The patient be allowed to come out after 4 hours. Frequent contacts at times of stress are important, especially when a patient is isolated. The other choices are not useful because Answer 1, isolation, does not automatically imply the use of restraints; all furniture need not be removed (Answer 2), depending on the institution and the type of behavior exhibited by the patient; and there is no specific time limit (Answer 4), because time depends on individual behavior and the patient's individual needs. Eliminate the option with the global word "all." Next, eliminate the too-specific time frame ("4 hours") that is not based on the patient's behavior or safety. Then eliminate the option on restraints, which is a last-resort action. Now you can readily choose the simple, most obvious option about "frequent contacts. Which activity would be best for the nurse to suggest to a client who is depressed? Folding laundry or stapling paper sheets for charts. Playing checkers. Doing a crossword puzzle. Ice skating. An undemanding task that the client could finish would allow a feeling of successful accomplishment. Answers 2 and 3 require intellectual activity, which is usually slowed down during a depressive phase. Answer 4 requires a skill that the client may not have and that might frustrate the client to learn; also, the client may not have the psychomotor energy for ice skating. Apply the process of elimination. Eliminate the two activities that call for intact cognitive functioning (which is slowed down in depression). The best answer does not involve a great deal of physical exertion, either (Answer 4). A woman patient says to the nurse, "That patient over there is a lesbian." What is the best response by the nurse? Are you afraid she will attack you? That woman is not a lesbian. What did the woman do that makes you think she is a lesbian? Then stay away from her. The nurse should encourage the patient to explain her statement in order to understand the experience she is having. Answer 1 is incorrect because it offers an interpretation that may or may not be true. Answer 2 is incorrect because it denies the patient's perception without clarification. Answer 4 is incorrect because the nurse agrees with an unsupported statement. When none of the options is appropriate, sound out the responses, and choose the option closest to an attempt to seek clarification. Which activity could a nurse suggest that would be best for a client with hyperactive behavior? Solitary activity, such as reading. Hammering on metal in a jewelry-making class. Playing chess. Competitive games. It will provide energy release without the external stimuli and pressure of competitive games (Answers 3 and 4). Reading (Answer 1) usually requires sitting, which a client who is hyperactive cannot readily do. Apply theory about manic behavior (hyperactivity) and select the only option that helps the patient to externalize the energy (Answer 2), without additional stimuli (competitive games). A patient says to his mother, "You are controlling me." The mother asks the nurse what he may have meant. What is the best response by the nurse? He is upset and thinks you are taking charge of him. He resents always having to meet your expectations. I can't tell you. You will have to ask him. I think you can ask your son that. Do you want me to stay with you while you ask him? The mother needs to ask the patient, not the nurse, but the nurse should also support the mother and encourage her to interact with her son. Answers 1 and 2 are incorrect because they are interpretations that state opinions about the patient without his participation. Answer 3 is incorrect because no support is given to the mother. First, eliminate the two options that are interpretive (Answers 1 and 2); then choose the option that redirects the mother to the patient while providing support to the mother (Answer 4). When a client exhibits signs of amnesia, the nurse knows that this behavior is probably related to: Selectively forgetting and storing unacceptable thoughts, wishes, and impulses in the unconscious mind. Conscious, deliberate forgetting. Transferring to another situation an emotion felt in a previous situation where its expression would not have been acceptable. Unconscious imitating of the manners, behavior, and feelings of another. By definition, this is repression. Answer 2 is suppression; Answer 3 is displacement; and Answer 4 is identification. Review definitions of defense mechanisms in order to select the only correct answer. In caring for a patient at risk for suicide, the most important nursing action is to: Maintain constant awareness of the patient's whereabouts. Ignore the patient as long as he or she is talking about suicide, because a suicide attempt is unlikely. Relax vigilance when the patient seems to be recovering from depression. Administer medication. The patient must be constantly observed. Answer 2 is incorrect because all suicidal talk and gestures are to be taken seriously. If the patient talks about suicide, there may be an attempt. Answer 3 is incorrect because suicide risk is greater when depression is lifting, requiring greater vigilance. Answer 4 is incorrect because medication for depression may take up to 2 weeks to decrease symptoms, and the patient needs vigilant surveillance now. Key words; "most important nursing action." Eliminate the option that is a myth (Answer 2). Focus on the contradictory options: "constant awareness" vs. "ignore the patient" and "relax vigilance." Choose "constant awareness." Giving medications is not the most important nursing action. A client who attempted suicide recently remarked to the nurse the next morning, "Let's not think about that now. Maybe I'll feel like thinking about it later." The nurse identifies this as: Blocking. Denial. Suppression. Repression. By definition, this is the conscious, deliberate effort to avoid talking or thinking about painful, anxiety-producing experiences. Answers 1,2, and 4 are incorrect terms for the example given in the stem. Review definitions of coping mechanisms in order to select the correct answer. After a mastectomy, a woman says, "My husband won't love me anymore." What would be the most therapeutic response by the nurse? Of course your husband loves you. Tell me what has happened that makes you think your husband won't love you anymore. If you stop crying and fix yourself up, you will look good to your husband. Do you think your husband won't love you because you have lost a breast? This question attempts to get a specific description of what has happened and will allow the client to describe grief and feelings of low self-worth because of loss of a breast. Answer 1 is incorrect because it offers false reassurance. Answer 3 is incorrect because it is a stereotyped response to a woman and denies the client's actual loss. Answer 4 is incorrect because it is an interpretation that, although possibly true, the client may reject. Resolution of grief is better achieved if the client can state a connection. First, eliminate the options that give false reassurance (Answer 1), offer a stereotyped response (Answer 3), and are interpretive (Answer 4). Then, select the option that is an example of therapeutic communication, which helps the patient to elaborate and look for connections between feelings/belief and events. Repetitive hand washing is often seen when a client is experiencing guilt feelings. This ritualistic behavior can be described as a mechanism whereby the client attaches significance to the act of washing. The nurse would identify this behavior as: Symbolism. Fantasy. Isolation. Conversion. Symbolism is the most clearly descriptive mechanism. Answer 2, fantasy, is a mental activity; Answer 3, isolation, is the exclusion from awareness of a feeling; Answer 4, conversion, is a disruption of motor or sensory functioning. Review definitions of defense mechanisms to select the only correct answer. In conducting an assessment interview, the nurse needs to be aware that self-destructive behavior is determined by: A variety of factors, with the same factors present in each individual. Genetic disturbances. Interpersonal disturbances. A variety of factors, different for each individual. A variety of factors can cause self-destructive behavior, and these differ for each individual. Hence, Answers 2 and 3 are not the best choices because, although correct, they are examples of a variety of factors; Answer 1 is the opposite of the correct answer. Choose the most inclusive answer when two options are examples of a main point. Eliminate Answer 1, which is partially the same as Answer 4 but also the opposite ("same" vs. "different" factors). A client shouts at the nurse one morning, "Why do you waste your time on me? I'm not sick; I don't need you. Go talk to other patients. They are really sick!" The nurse identifies this as: Reaction formation. Denial. Intellectualization. Rationalization. Denial is the mind's way of protecting the self-system from a disturbing reality. Answer 1, reaction formation, is an expression of an attitude opposite to unconscious feelings; Answer 3, intellectualization, is giving rational reasons without expression of underlying feelings; Answer 4, rationalization, is the attempt to make one's behavior look like the result of logical thinking. Review defense mechanisms to select the only correct answer. Which term would the nurse use to describe the experience of an individual who thought he heard a machine gun when his neighbor's lawnmower backfired as she was mowing the lawn? Delusion. Hallucination. Identification. Illusion. This is correct by definition. Answer 1 is incorrect because delusion is a fixed idea arising out of a person's inner needs and contrary to observed facts. Answer 2 is incorrect because a hallucination is a misperception that is unrelated to an external stimulus. Answer 3 is incorrect because identification is the process of taking on another person's attribute. Apply knowledge about adaptive and maladaptive coping mechanisms. Notice the option that is different (i.e., not a coping mechanismAnswer 4). For an educated guess, ask yourself: "Which of the following is not like the others?" Then, select it (this helps to focus on patterns.) It would be important for the nurse to implement definite suicide precautions for a patient who is depressed if the patient's mood changed suddenly to one of: Cheerfulness. Psychomotor retardation. Agitation. Hostility. A person who has settled on a plan for suicide may become more cheerful. Answer 2 is incorrect because a person who is severely retarded in the psychomotor area cannot carry out a suicide act. Answers 3 and 4 are incorrect because the patient is more likely to be hostile and agitated if he or she does not have a suicide plan. Agitated behavior can also represent the need to "repent" for sins thought to be committed. Look at the two sets of contradictory options: "cheerfulness" (1) vs. "hostility" (4); "psychomotor retardation" (i.e., slowing down) (2) vs. "agitation" (3). Hostility and agitation can be paired and, therefore, ruled out; that leaves "cheerfulness" as the option that is different, and the one to select ("which of the following is not like the others?"). The nurse knows that the most characteristic task of puberty and adolescence, according to Erikson's stages of psychosexual development, is: Identity versus role confusion. Initiative versus guilt. Ego integrity versus despair. Intimacy versus isolation. This is the correct match between age period and developmental task. Answer 2 refers to preschool age, Answer 3 is characteristic of "maturity" in later years of life, and Answer 4 refers to young adulthood. Review age-related psychosocial growth and development stages according to Erikson. A patient recently attempted suicide by slashing the wrists. The crisis intervention nurse and physician agree that hospitalization is not necessary for this patient; therefore, the nurse needs to: Wish the patient luck and terminate the session. Make an appointment for tomorrow and give the patient a telephone number where the nurse can be reached tonight. Make an appointment for the patient in 2 weeks, when the wrists might be healed. Tell the patient to make an appointment when she or he wants to, at the local mental health clinic. On principle, the crisis intervention nurse needs to be immediately available to the patient. Answer 1 is incorrect because it abandons the patient. Answer 3 is incorrect because the patient needs to deal with the situation immediately. Answer 4 is incorrect because the patient might decide that the crisis intervention nurse is not interested in helping, and the patient needs immediate assistance. Continuity of care is the concept to apply in selecting the next step in time sequence. A 10-year-old boy was admitted to the hospital for a tonsillectomy. In the morning, the nurse notes that the bedding is wet. There are several boys his age in the room. Which initial approach would best demonstrate a nurse's understanding of enuresis and this patient's stage of growth and development? While proceeding to change the wet linens, ask him what sports he likes best, purposely ignoring the wet bed by staying on impersonal topics. Draw the curtains around his bed while changing the linen, saying, "I know that this must be embarrassing to you." Say nothing while changing the bed; return at another time, when the other boys are not in the room, and explain to him the medical-emotional reasons for enuresis. Sit down on the bed and convey acceptance of him as a person rather than focusing on the wet bed. The goal is to preserve ego strength through acceptance and respect of the patient as a person. Answer 1 focuses on the tangential and irrelevant; Answer 2 makes the problem more obvious to others in the room and makes an assumption without validation about how the patient must feel; Answer 3 is incorrect because it is usually not helpful to give a rational explanation for an emotional difficulty related to enuresis. Focus on the option with the key word "acceptance. A patient with an antisocial personality disorder arouses anxiety and frustration in the staff and tends to intimidate by manipulative behaviors. One morning the patient shouts at the nurse, "Since you won't give me a pass, go away, you fat pig, or I'll hit you." What is the most effective response by the nurse to a client who threatens or derogates? You are rude and I don't like it. It makes me not want to talk with you. That kind of talk will keep you here longer. What did I do wrong? I don't like to hear insults and threats. What is important about getting the pass today? The nurse must state feelings, without anger; show no intimidation; and then help the patient examine what he or she is doing and why. Answer 1 is incorrect because it points the finger in an angry, accusatory way and labels the patient in turn ("You are rude"). Answer 2 sounds like "Big Nurse" authoritarian and punitive. Answer 3 may place the nurse in a position to be intimidated and "kicked" by the patient. Sounding out the response may help eliminate the threatening-sounding answers (1,2) and the apologetic-sounding response (3). The better response to choose is one in which the nurse gives feedback and uses open-ended communication to seek clarification (4). In assessing the behavior of a child with autism, the nurse notes that a symptom that characteristically differentiates this child from one with Down syndrome is: Retardation of activity. Short attention span. Difficulty in responding to a nurturing relationship. Poor academic performance. Most children with Down syndrome are affectionate and enjoy being held and cuddled, whereas the opposite is usually the case with a child who is autistic. All other responses (1, 2, and 4) may apply to both Down syndrome and autism. Apply knowledge about characteristics of Down syndrome and autism to select an important difference related to interpersonal behavior. It is important for a nurse to understand that a patient's repetitive hand washing is probably an attempt to: Punish himself or herself for guilt feelings. Control unacceptable impulses or feelings. Do what the voices the patient hears tell him or her to do. Seek attention from the staff. A ritual, such as compulsive hand washing, is an attempt to allay anxiety caused by unconscious impulses that are frightening. Answer 1 is incorrect because it is the opposite of what the hand-washing ritual is intended to dothe ritual is aimed at absolving guilt, not punishing. Answer 3 is related to psychotic symptoms and not at all relevant to symptoms of ritualism. Answer 4 is incorrect because hand washing is aimed at relief of guilt and self-help to reduce anxiety, not at seeking attention from staff. Apply theory about psychodynamics underlying ritualistic behavior: getting a handle on and seeking relief from anxiety (rather than punishment). Eliminate the two other options because they do not relate to ritualism. In establishing a therapeutic nursing approach with a client who abuses and is dependent on substances, the nurse primarily needs to: Promote a permissive, accepting environment. Use a straightforward and confronting approach. Meet the client's need for a chemical substitute for the drug. Prevent the client's use of the addictive drug. It is important to provide external support in helping develop the superego. Answer 1 may promote manipulative behavior in the client. Answer 3 may foster additional dependence. Preventing the client's use of drugs (Answer 4) is not the primary step in building a nurse-client relationship based on therapeutic communication. Note the key word, "primarily"; then, focus on two contradictory options: permissive vs. confronting. Next, apply theory regarding addictive personalities and select "confronting" (Answer 2). At 2:30 a.m., a client walks out to the nurse's station complaining that he is choking, suffocating, weakening, and dying. He demands a cigarette. What is the best response by the nurse? Refuse and tell him it is against the rules. Call the doctor and inform the doctor of the client's request and behavior. Refuse and tell him the cigarettes are locked. Give him a cigarette and stay with him while he smokes. The client is anxious and needs someone with him. Answer 1 is incorrect because it ignores the client's anxiety and needs. Answer 2 is incorrect because it also ignores the client's anxiety, and uses the doctor as an excuse to ignore his needs. Answer 3 is incorrect because it also ignores the client's anxiety and needs, and gives a poor reason for refusal. First, recognize symptoms of anxiety; then, choose the only answer that appears to focus on the patient's anxiety (although you may not like this answer). What approach can the nurse use to best handle a client's disturbed behavior? Approve the behavior. Maintain consistency of approach. Encourage the client not to express negative opinions. Interpret for the client the reasons for the behavior. Consistency lets clients know consequences of behavior and develops trust. Answer 1 is incorrect because the nurse cannot approve all behavior (e.g., destructive behavior). Answer 3 is incorrect because it can be therapeutic to express negative opinions. Answer 4 is incorrect because interpretation of behavior is not always advisable. Clients may use interpretations of behavior to avoid consequences of behavior or may see them as an excuse not to change behavior. Look at the option with the key word, "consistency," as the better answer. Eliminate Answers 3 and 4 because they are examples of nontherapeutic approaches. The overall client goal in rape counseling is to help the victim: Forget the incident and repress her feelings in order to be able to carry on with her life. Identify the rapist in a court of law. Accept her part in the rape. Acknowledge, face, and resolve the reaction she is experiencing. The victim needs to engage in expression of the experience, which will assist her to work through her feelings so that the experience may not interfere in future interpersonal relations. To repress the incident, as in Answer 1, would make it continually interfere in her relationships. Answer 2 is done only after Answer 4 has been accomplished. Answer 3 is incorrect because the rape victim has no "part" in the rape. Focus on the key words in the stem: "overall client goal. Which is the most appropriate response to a client who states emphatically, "I hate them"? I will stay with you as long as you feel this way. Tell me about your hate. I understand how you can feel this way. For whom do you have these feelings? The nurse is asking the client to clarify and further discuss feelings. Answer 1 is incorrect because while staying with the client might convey acceptance, it does not help the client clarify or deal with feelings. Answer 3 is incorrect because it cuts off any further response from the client and because it is doubtful that the nurse can understand this person's feelings without clarification. Answer 4 is incorrect because it is more important to clarify the client's feelings than it is to understand the object of hate. Best answer is an attempt to clarify feelings, rather than to focus on facts ("For whom .."). The nurse observes for signs of heroin withdrawal, which may include: Rhinorrhea, sneezing, and high fever. Pupillary dilation, diaphoresis, and weight loss. Pupillary constriction, vomiting, and pruritus. Choreiform movements and frequent lip wetting. Note the eyes: when a person is on heroin, the pupils are constricted; during withdrawal, they are dilated. Withdrawal does not usually include high fever, pupillary constriction, or choreiform movements, as in Answers 1,3, and 4. Note two contradictory options about the eyes ("dilation" vs. "constriction"), and know which applies to withdrawal vs. being on heroin. The nurse will look for what likely outcome of methadone treatment for heroin abuse and dependence? Sedation. Euphoria. Neuritis. Blocking of the euphoric effect of heroin and elimination of craving. Methadone is a synthetic narcotic and has no euphoric effect. Methadone does not produce sedation (Answer 1), euphoria (Answer 2), or neuritis (Answer 3). Eliminate the three options that are not related to methadone. Review effects of methadone. An acutely agitated client becomes increasingly aggressive. The staff's verbal attempts to stop the aggressive behavior are not effective. The client begins to shout threats at the staff and other clients, throws furniture, breaks windows, and hits, kicks, and bites other clients and staff. The client has a prn order for medication when agitated. Which action should the nurse take initially? Orient the client to reality and place the client in a well-lit, quiet room. Give the ordered tranquilizer and put the client in bed with the side rails up. Lock the client in his or her room and call the doctor. Have at least two staff members physically restrain the client and take the client to a quiet room. With concern for danger to the other clients, staff, and the environment, it is essential for the client to be restrained at this time. The other choices are incorrect because orientation and a quiet environment alone do not provide for safety when the client's agitation is out of control (Answer 1); the initial delay in onset of effectiveness of the tranquilizer does not immediately provide for the safety needs of other clients, staff, and the environment (Answer 2); and locking the client in his or her room eliminates only the danger to othersadditional measures would be needed to provide for the safety of this client (Answer 3). Note the key word, "initially." Know when it is acceptable to use restraints. A teenage patient has a history of stealing cars and traffic violations. The home environment has been permissive, and the teenager has been overly familiar and obsequious with the nurses. A new nurse, about to leave the locked unit, is holding the key as the patient approaches and eagerly offers to unlock the door for the nurse, saying, "The other nurses let me." Which first response by the nurse would be most appropriate? Let the patient turn the key in the lock, but stay close while the patient does it. Ask the patient why he or she wants to unlock the door. Tell the patient in a nice way that this is not allowed. Go to the head nurse and ask if it is all right for the patient to unlock the door. Based on the patient's history of antisocial behavior, he or she is probably attempting to use the nurse for his or her own purpose and is not truthful. Therefore, it is best that the new nurse on the unit go directly to the head nurse to check on what is permissible and not accept the patient's word that it is permissible. Answer 1 is not helpful because allowing the patient to unlock the door may feed into the manipulative attempt by the patient to get off the unit. Answer 2 is incorrect because asking a "why" question is not a therapeutic communication. Answer 3 is incorrect because this option places the new nurse in an argumentative position with the patient, who is likely to become defensive and say, "Oh, yes. I am allowed to open doors." Note the key word: "new" nurse. Review the theory about acting-out and manipulative behavior. Select the answer that calls for consistency among staff (4). Several staff members voice their frustrations about a patient's constant questions, such as "Should I go to the day-room or should I stay in my room?" and "Should I have a cup of tea or a cup of coffee?" Which interpretation about this behavior will help the nursing staff deal effectively? The patient's inability to make decisions reflects a basic anxiety about making a mistake and being a failure. The patient's indecisiveness is aimed at testing the staff's reaction and acceptance of him or her. The patient's dependence on others (staff) is a symptom that needs to be interrupted by firm limit setting. The patient's need to ask questions is a bid for attention. Limit setting is an important intervention with a patient who exhibits excessive, constant dependence on others for simple, seemingly inconsequential decisions in everyday life. The other choices are wrong because the situation presented provides insufficient data on which to base interpretations related to fear of failure (Answer 1), a need to test for staff acceptance (Answer 2), or a bid for attention (Answer 4). Eliminate the three options for which there are no data in the stem to validate the interpretations (Answers 1,2, and 4). In providing dietary instructions to an Orthodox Jewish client who is depressed, the nurse needs to know that which practice would be prohibited in dietary Kosher laws? Eating dairy products with meat. Eating meat from animals with cloven hoofs. Eating fish with scales and fins. Eating unleavened bread during the 8 days of Passover. This is the only correct answer regarding dietary prohibitions. Answers 2,3, and 4 are allowed. Knowledge regarding Orthodox Jewish dietary laws is needed to select the correct option. Note the key word: "prohibited" (i.e., not not allowed). A patient with antisocial behavior flatters the nurse. What is the patient trying to do? The patient wants something in return The patient wants the nurse to like him. The patient needs attention. The patient is trying to redirect the focus of the nurse-patient interaction. Manipulation is a characteristic antisocial behavior. Flattery is a form of manipulationwith hidden agenda, to get what the patient wants, whatever that may be. Answer 2 may or may not be the agenda behind the flattery. Answers 3 and 4 are also possible examples of what the patient wants. When more than one answer is plausible, choose the one that covers them allthe "umbrella" answer (1). A patient with schizophrenia is banging on the hallway door leading to the outside, saying he needs to go to an appointment. What nursing intervention is needed? Ask the patient to move away from the door. Ignore this behavior. Escort the patient back into the room. Tell the patient that he cannot bang on the door. Gentle but firm guidance and nonverbal direction is needed to intervene when a patient with schizophrenic symptoms is being disruptive. Answer 1 requires the patient to listen and respond accordingly. This behavior is disruptive and should not be ignored (Answer 2). Answer 4 says only what cannot be done, without providing an alternative activity. Knowing the theory about characteristics of schizophrenia (e.g., autistic behavior, thought disorders) would help eliminate Answers 1 and 4. Ignoring disruptive behavior is not appropriate. The process of elimination leads to Answer 3 as the best answer. In preparing a patient for ECT, the nurse knows that succinylcholine (Anectine) will be administered for which therapeutic effect? Skeletal muscle paralysis. Short-acting anesthesia. Decreased oral and respiratory secretions. Analgesia. is correct because it is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation. Answer 2 is incorrect because it describes the action of methohexital (Brevital), which is administered in the treatment room before ECT. Answer 3 is incorrect because it describes the action of atropine sulfate, given IM 30 minutes before treatment, to decrease secretions and counteract vagal stimulation effects induced by ECT. Answer 4 is incorrect because analgesia is not required in ECT (before, during, or after), and it is not related to Anectine. Knowledge of the three standard drugs used in ECT and their effects will lead to the best answer. The nurse can anticipate that the person most likely to be at risk for depression is: An elderly person with previous depressive episodes. A middle-aged man who is a moderate alcohol drinker. A housewife with three school-age children. A nursing student at exam time. is correct because depressive episodes are often recurrent. Answers 2,3, and 4 may or may not experience depression. Answers 2 and 4 are more likely to experience anxiety. There does not appear to be any reason to expect that a housewife with three children in school would be at risk for any particular emotional distress (Answer 3). Match the key word in the answers, "depressive," with the key word in the stem, "depression. In admitting a patient with Alzheimer's to the unit, which placement variable would have the highest priority: Place the patient with a roommate. Place the patient without a roommate. Place the patient close to the nurses' station. Place the patient at a distance from the nurses' station. Nursing observation is easier if the patient with Alzheimer's is nearby. Therefore, Answer 4 is incorrect. A roommate may (Answer 1) or may not (Answer 2) be all right, but facilitating nursing observations is the highest priority for a patient with memory problems and confusion who is a safety risk for wandering off the unit. Focus in on the best option by first narrowing choices to two that are contradictory (with/without a roommate; near/at distance from the nurses' station). Then ask, Is it roommate or proximity to nurses' station that is the priority? Next, consider what goal is met by being near the nurses' station rather than a roommate. Answer: safety from wandering. During a home health assessment visit to an elderly patient living alone, which aspect of lifestyle noted by the nurse would be of greatest concern? The family visits only twice a month. The family maintains only phone contact daily. The patient uses a cordless telephone rather than a standard phone. The patient prefers not to attend a senior citizen center for meals and recreation. This is the correct answer because it lets the nurse know that contacts with the elderly person are infrequent and that ongoing assessment of needs and health concerns is not likely to occur. Answer 2 is incorrect because it is not the greatest concern, as long as there is the opportunity for assessment by phone. A cordless phone is a good idea rather than a great concern (Answer 3). Although isolation is further increased by not wanting to go to a senior citizen center, it is not of greatest concern (Answer 4). Put logic and reasoning to work here. Look at patterns in the stem: two options focus on family (1, 2), one option focuses on a phone instrument (3), and another option focuses on a community agency (4). A hospitalized patient with Alzheimer's disease is often found wandering in the streets. What measure(s) should be taken in the unit to prevent the patient from wandering off? Place the patient in daytime restraints. Place the patient in nighttime restraints. Provide a security guard at the door. Use electronic surveillance devices. This answer is concerned with accident prevention and is a means of observation of the patient. Answers 1 and 2 are incorrect because the use of restraints is inappropriate and not justified. Having a security guard is not realistic (Answer 3). Use the process of elimination. Eliminate the two options dealing with restraints; eliminate the most unlikely option (Answer 3); Answer 4, therefore, is the best answer. What parental behavior toward a child during admission procedure should cause the nurse to suspect child abuse? Acting overly solicitous toward the child. Ignoring the child. Expressions of guilt. Flat affect. This is an example of reaction formation, a coping mechanism. Answer 2 is incorrect because "ignoring" is the opposite of Answer 1, the correct choice. Answer 3 is incorrect because guilt may be manifested by being overly solicitous (Answer 1). Answer 4 is incorrect because "flat" is the opposite of an emotional reaction/action (overly solicitous). Remember Shakespeare: "Methinks the (lady) doth protest too much"showing care and concern (love) but inflicting harm (hate). Which nursing action would be best for a hospitalized patient who is constantly upset with the staff, easily angers, and frequently shouts at the nurses? Request that the patient be moved to another unit. Schedule a conference with the MD, nurse manager, and patient about this behavior. Contact social services to meet with the patient and family about the problem. Involve the patient and family in the development of the care plan. The patient is probably experiencing a loss of control over the hospitalization situation. Initially the patient and family should be included in planning care, which returns decision making to the patient and decreases frustration. Answers 1 and 3 shift the problem rather than attempt to resolve the issue. Answer 2 involves the patient but brings in an authority figure (the MD), which may be seen as punish ment or "parental" by the patient. Look for the choice that gives the patient the most control; do not "pass the buck" to someone else (MD, social services, etc.) Which nursing action would be most appropriate for a nursing diagnosis of "self-esteem disturbance"? Compliment the patient as often as possible. Assist the patient to set reasonable, achievable goals. Assure the patient that all needs will be met. Encourage the patient's family to praise the patient verbally. The patient needs to experience personal success. Setting reasonable and achievable goals will affirm the patient's value and ability to succeed. Answers 1,3, and 4 will most likely be meaningless to a patient who does not feel important or successful. The choices are all verbal with no active participation by the patient. Maximize the patient's actions. Choose an option that "assists" the patient to do something. During a group education session on recovering from a myocardial infarction, one patient blurts out, "I don't agree with what you are saying." The best response would be: Tell us where your information came from. I'll talk to you after the class is over. I've had patients say that before, but they were wrong. Give us an example of what you feel is incorrect. It is important to recognize differences of opinion and clarify patient perceptions of information presented without appearing defensive or putting the patient on the defensive. The patient may be anxious following an MI, and the out burst may be an indication of fear and anxiety. Answers 1,2, and 3 are defensive or avoiding responses by the nurse. Only one option acknowledges the patient's statement as important to address. Nursing preparations for a gastroscopy procedure include: Holding the patient NPO for 24 hours before the procedure. Having an operative or procedure permit signed. Reassuring the patient that gastroscopy is not an uncomfortable procedure, though he or she will need to lie quietly. Removing dentures and administering pain medication before the procedure. All permits must be signed before the procedure. Patients are NPO 6-8 hours, not 24 hours (Answer . Gastroscopy is an uncomfortable procedure; to mislead the patient by saying it is not uncomfortable (Answer can only increase anxiety and discomfort during the procedure. This procedure involves the passage of a long tube into the stomach, with a lighted, mirrored lens that permits direct visualization of the stomach mucosa. The patient must lie quietly during insertion of the tube to prevent perforation of the esophagus. Usually sedatives, not pain medications (Answer , are given before the procedure. One answer is different from the others. Three of the choices deal with physical preparation. Which nursing action is the first priority during a generalized tonic-clonic seizure episode? Observe and record all events that occur before, during, and after the seizure. Maintain a patent airway by turning the head to the side. Protect the patient from injury. Monitor vital signs, with special attention directed to respiratory status. The first priority is to protect the patient from injury. Do not restrain the patient's arms or legs, but make sure he or she does not hit anything. Protect the head with the nurse's hand, a towel, or a jacket. During the initial tonic phase, the patient usually stops breathing for up to a minute. There is no cause for alarm, as spontaneous breathing will, in most patients, return with no harm. In the absence of breathing, airway patency by this position change (Answer is not the first priority. Muscle contraction will prevent "positioning" of the head. A padded tongue blade, once indicated during a seizure, is also no longer used. Answers 1 and 4 are appropriate nursing actions after the seizure has ended. The correct choice is broadest, encompassing the other choices. Key word: first priority. Which nursing intervention would be the most beneficial in preparing the patient psychologically for ileostomy surgery? Include the patient's family in preoperative teaching sessions. Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy. Thorough, brief explanation of all preoperative and postoperative procedures. Have a member of an "ostomy club" visit the patient. Although all of these interventions are appropriate in the preoperative period, research indicates that the best postoperative outcomes are related to the patient's reduced preoperative anxiety levels. Patients who deny apprehension and refuse information, as well as those who are highly anxious and who are unable to ask questions or assimilate information, have the most difficult postsurgical course. Patients who are able to express their concerns and who are given emotional support as well as accurate, brief explanations tend to have less pain and fewer postoperative complications. Answers 1,3, and 4 do not address the patient's need to verbalize concerns. The correct answer is the only one that asks the patient what he or she would like to know. Which of the following indicates circulatory constriction in the patient with a newly applied long leg cast? Tingling and numbness of toes. Inability to move toes. Blanching or cyanosis of toes. Complaints of pressure or tightness of the cast. Signs of circulatory constriction include blanching (delayed capillary refill) and cyanosis, swelling of the toes, pain that is out of proportion for the type of fracture, and temperature changes. Tingling and numbness (Answer , loss of movement (Answer , and constant pain (Answer are symptoms associated with constriction or pressure on a peripheral nerve. Requires knowledge of difference between motor, sensory, and circulatory signs/symptoms. Paralytic ileus is described by the nurse as: Edema of the intestinal mucosa. Acute dilation of the colon. Absent, diminished, or uncoordinated autonomic stimulation of peristalsis. High, tinkling bowel sounds over the area of obstruction. Paralytic ileus is characterized by diminished, absent, or uncoordinated bowel sounds due to inappropriate or absent autonomic nervous system (vagal) stimulation of the intestinal tract. Paralytic ileus may occur due to anesthetic interruption of autonomic outflow or hypokalemia. Edema of the intestinal mucosa (Answer is usually found with inflammation or ulcerative colitis. Acute dilation of the colon (Answer and high, tinkling bowel sounds (Answer are associated with large bowel obstruction. Look for words in the answer that define "paralysis." The doctor has ordered ambulation on crutches, with no weight bearing on the affected limb. An appropriate crutch gait for the nurse to teach the patient would be: Two-point gait. Three-point gait. Four-point gait. Tripod gait. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing through crutch gaits may also be used when only one leg can be used for weight bearing. Answers 1 and 3 are utilized when weight bearing is allowed on both feet. Answer 4, the tripod gait, is utilized when the patient has little or no sensation or movement (paralysis) in the lower limbs. Need to know which limbs are used with each gait. Key words: "no weight bearing." Nursing preparation for an upper GI series includes: NPO for 24 hours before the procedure. Administering an enema or cathartic to enhance visualization. Discouraging the patient from smoking the morning of the procedure because smoking can stimulate gastric motility. Instructing the patient that the test involves insertion of a rubber gastroscopy tube. Patients are NPO and encouraged not to smoke or take medications the morning of an upper GI series. Patients are NPO for 6-8 hours, not 24 hours (Answer . Enemas and cathartics (Answer are not administered before an upper GI series; however, they are given after the series, to aid in the elimination of the barium. The test involves an x-ray, using a barium swallow as contrast medium. Gastroscopy (Answer is the direct visualization of the stomach. Note the time element: before; this eliminates #2. Eliminate #1 because being NPO for 24 hours is excessive. #4 is the description for a different test, not for UGI series. Burns are classified according to the depth of tissue destruction. The nurse would recognize a deep partial-thickness burn because the burn: Involves the epidermis only. Extends to the dermis and is very painful. Extends to subcutaneous tissues and is rarely painful. Extends to muscle and bone and is very painful. Deep partial-thickness burns involve both the epidermis and some of the dermis. They have a pink-red appearance and are characterized by moisture or blisters. Deep partial-thickness burns are very painful, because nerve endings remain and maybe exposed to the air. A superficial partial-thickness burn involves only the epidermis (Answer . An example is sunburn: the skin is usually red and dry. In full- thickness burns, subcutaneous tissue, muscle, and even bone are also involved (Answers 3 and . Typically, a full-thickness burn is white, gray, or charred in color and is dry and leathery in appearance. Nerve endings have been destroyed, so the area is painless. The key word is "deep." Three of the choices are not deep. The nurse's best explanation of the basic emotional issue underlying or contributing to the development of ulcers would be: Anxiety neurosis. Dependence-independence conflict. Repressed anger and hostility. Compulsive time orientation. Some authorities believe that the psychosomatic issue contributing to ulcers is an unresolved dependence-independence conflict. This conflict frequently prevents the patient from accepting a dependent role, even on a temporary basis. However, the unresolved dependency wish that many of these people have frequently results in irritable, angry behavior when treatments are not exactly on time. Other psychosomatic research has linked anxiety and neurotic behavior (Answer with the occurrence of angina pectoris; repressed anger and hostility (Answer with the development of rheumatoid arthritis; and compulsive time orientation (Answer (type A personality) with onset of myocardial infarction. Ask which emotional response would most likely stimulate a parasympathetic (stress) response. Which patient problem relating to altered nutrition is a consequence of impaired physical mobility? Increased appetite. Decreased protein catabolism. Increased carbohydrate needs. Increased secretion of digestive enzymes. Increased carbohydrates are needed for healing and tissue repair. Anorexia, not increased appetite (Answer , is a problem. Increased, not decreased protein catabolism is present (Answer . Digestive enzyme secretion is decreased, not increased (Answer . Need to know the effects of immobility on metabolism. Selecting Answer 2 would be too obvious! The signs and symptoms of open-angle glaucoma are related to: An imbalance between the rate of secretion of intraocular fluids and the rate of absorption of aqueous humor. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia. An infectious process that causes clouding and scarring of the cornea. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. Glaucoma is an imbalance between the rate of secretion of intraocular fluids and the rate of their absorption. Glaucoma may be acute/closed-angle (obstruction of the angle between the cornea and iris) or chronic/open-angle (obstruction occurs proximal or distal to the angle). It is characterized by increased intraocular pressures. Narrowing of the arterioles and retinal ischemia (Answer are the result of prolonged hypertension. Clouding of the cornea (Answer is not seen in glaucoma. Buckling of the retina (Answer is associated with retinal detachment. Only one choice describes a problem of imbalance, the major problem in glaucoma that leads to increased intraocular pressure related to the imbalance. Patients suffering from dumping syndrome should be advised by the nurse to: Drink liquids between meals. Drink liquids only with meals. Drink liquids any time they want. Restrict fluid intake to 1200 mL/day. Patients experiencing dumping syndrome should be advised to ingest liquids between meals rather than with meals (Answer or at any time they desire (Answer . Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. Six small meals rather than three large meals, as well as resting after eating, are also measures used to prevent the occurrence of symptoms, which usually disappear over time. There is no need to restrict the quantity of fluids (Answer , just the timing. Key point is a time factor (when). Decreasing volume at meal time, not in general, is the key. Fluid spreads the process. Urinary output is closely assessed after nephrectomy. Which assessment finding is an early indicator of fluid retention in the postoperative period? Increased specific gravity of urine. Daily weight gain of 2 lb or more. A urinary output of 50 mL/hr. Periorbital edema. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance. Increased specific gravity of urine (Answer indicates that the patient is underhydrated rather than overhydrated. A urinary output of 50 mL/hr (Answer is the desired minimum following renal surgery. Periorbital edema (Answer is a later sign of excess fluid retention. Key word: "early" indicator. Daily weight is the best indicator. Which statement by the nurse accurately describes the Miller-Abbott tube? A double-lumen tube, with one lumen leading to the inflatable balloon and the other lumen used for aspiration. A plastic or rubber tube with holes near its tip facilitating withdrawal of fluids from the stomach. A single-lumen, saline-, air-, or water-weighted tube approximately 6 feet long. A 10-foot-long rubber tube with a saline, air, or water bag at its end. The Miller-Abbott tube is a double-lumen tube, with one lumen leading to the inflatable balloon and the other lumen used for aspiration of intestinal contents. Answer 2 is an example of a Levin tube, used for gastric suction. Answer 3 is an example of a Harris tube, and Answer 4, a Cantor tube, both used for intestinal decompression, like the Miller-Abbott. Need to know which tubes are single vs. double lumen. If treatment with thyroid hormone is effective, the nurse should expect: Diuresis, a decrease in pulse rate, and an increase in blood pressure. Diuresis, a widening pulse pressure, and an increase in both temperature and respiratory rate. Increased pulse rate, decreased respiratory rate, and decreased puffiness. Weight loss, increased diastolic blood pressure, and decreased pulse rate. If treatment with thyroid hormone is effective, there should be an overall increase in metabolic rate and a decrease in fluid retention; that is, increased blood pressure, pulse rate, pulse pressure, temperature, and rate and depth of respirations. As a result of improved renal blood flow, glomerular filtration and urine output should also increase, thus reducing the weight gain due to fluid retention. Answers 1, 3, and 4 are incorrect because each contains at least one outcome that is not consistent with improved status. Know the physiological effect of the thyroid on the body. ?Thyroid function = ?BP, P, T, R, pulse pressure = ?fluid retention. A patient was admitted to the hospital with deep partial-thickness burns of the left leg and thigh. The nurse would expect this patient's serum-sodium level to be within normal limits at the time of admission because: The pituitary has increased ADH release. Vascular fluid losses due to exudate and edema formation have resulted in hemoconcentration. Sodium has diffused from disrupted cells into the vascular compartment. Increased serum potassium has depressed aldosterone secretion by the adrenal cortex. Aldosterone secretion by the adrenal cortex is stimulated by decreases in cardiac output. Aldosterone acts to conserve sodium in the kidney tubules, passively increasing water reabsorption and improving fluid volume balance. Normally, if the patient had only a water loss, he or she would also be hypernatremic because of this mechanism. However, in burns the patient's hypovolemia (hemoconcentration) is due to both fluid and electrolyte loss in edema fluids, as well as through the denuded areas of skin. Answer 1 is not the best answer because, although ADH is being released, its action has not at this time prevented hemoconcentration. Answer 3 is incorrect because very little sodium is released due to cellular disruption. Sodium is the main cation of the extracellular fluid. Answer 4 is incorrect because increased serum-potassium levels stimulate the release of aldosterone. Think fluid shift and hemoconcentration early in burns. Nursing actions for patients with Addison's disease include: Providing a low-sodium diet. Restricting fluids to 1500 mL/day. Administering insulin-replacement therapy. Reducing physical and emotional stress. Because the patient's ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison's disease, so close observation of the patient's hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluids containing electrolytes, such as broths, carbonated beverages, and juices. Answer 1 is incorrect because it limits sodium. Answer 2 is incorrect because it limits fluids. Daily weights and intake and output records are essential for monitoring fluid balance. Drug therapy in Addison's disease is directed toward oral replacement of adrenocorticosteroids such as cortisone, prednisone, and fludrohydrocortisone (Florinef). Insulin (Answer is not required. Addison's is the reverse of Cushing's syndrome. Note the pattern in the options: three relate to physical aspects of care; one deals with stress. In this case, choose the one that is different. The nurse explains to a patient that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve: Stimulates increased gastric motility. Decreases gastric motility, thereby preventing the movement of HC1 out of the stomach. Stimulates both increased gastric secretion and gastric motility. Stimulates decreased gastric secretion, thereby increasing nausea and vomiting. The vagus nerve stimulates an increase in both hydrochloric acid secretion and gastric motility. Vagotomy not only decreases hydrochloric acid secretion but also alters the motility of the stomach and intestines; this may result in a sensation of fullness after meals, eructation, and abdominal distention. Answer 1 is incomplete. Answers 2 and 4 are the reverse of effects of vagal action. Look for a choice that would be similar to the problem that led to the gastrectomy. Note that both #1 and #3 are correct, but #3 incorporates #1. In planning care for a patient with hyperkalemia, the nurse knows that the treatment of choice to reduce hyperkalemia is: Morphine sulfate. Sodium polystyrene sulfonate (Kayexalate). Insulin and 50% glucose solution. Synthetic aldosterone. Potassium is transported back into the cells along with glucose; therefore the administration of insulin and glucose will facilitate the movement of potassium back into the cell. Sodium polystyrene sulfonate (Kayexalate) (Answer is a resin that attacks and binds potassium. It may be given either orally or as an enema; however, its use would not be indicated in this case unless more conservative means were unsuccessful. Morphine sulfate (Answer and synthetic aldosterone (Answer are not indicated for the management of hyperkalemia. The "choice" would always be to move K+ back into the cell, not get rid of it through diarrhea. Understanding that prolonged immobilization could lead to decubitus ulcers, the nurse plans interventions to prevent alterations in skin integrity. Which would be the least appropriate intervention? Use of a bed cradle. Giving backrubs with alcohol. Encouraging a high-protein diet. Frequent assessment of the skin. Alcohol is extremely drying and contributes to skin breakdown. An emollient lotion should be used. Bed cradles (Answer keep the pressure of bed clothing off pressure points. High-protein diet (Answer aids in the healing process. Assessment of skin (Answer is vital, to recognize any red areas. Think of the effect of each choice on the skin, using a true-or-false approach regarding prevention of decubitus. Note that the question asks for least appropriate. The nurse knows that the physiological response to the stress of extensive burns may result in the following complication in the postburn period: Curling's ulcer due to elevated serum Cortisol. Positive nitrogen balance due to mobilization of body proteins. Decreased hematocrit due to red-blood-cell agglutination by epinephrine. Hypothermia and hyperthermia due to failure of hypothalamic temperature regulators. The hypovolemia and shock that accompany burns greatly increase the body's stress response. Increased serum levels of norepinephrine, epinephrine, and aldosterone facilitate venous return and thus assist in maintaining cardiac output and blood pressure. The pituitary is also stimulated in the stress response to increase circulating levels of ADH (decreases water output) and Cortisol. Increased levels of the latter hormone are implicated in the development of Curling's ulcer (stress ulcer), which may develop in patients of all ages and with both minor and major burns. Generally, H2 antagonists and antacids are used to reduce its occurrence. Answer 2 is incorrect because negative nitrogen balance occurs due to protein mobilization for healing. Patients with burns are given high-protein, high-calorie meals and supple mental vitamins to promote wound healing. Answer 3 is incorrect because hemolysis of red blood cells and decreased hematocrit are primarily due to the injury itself rather than to epinephrine agglutination. In thermal burns, up to 40% of the red blood cell mass may be hemolyzed. Hypothermia is a problem in the postburn period but is the result of the loss of skin areas; hence Answer 4 is incorrect. The patient treated by the open or exposed method of burn therapy is particularly susceptible to chilling. Increased thermostat set tings and radiant heat lamps may be employed to aid in maintaining normal body temperature. Burns are a major stress; ulcers are caused by stress (Curling's ulcer is also known as stress ulcer). Several hours after a long leg cast has been applied, the nurse notices that the patient's toes have become edematous. The physician decides to bivalve the cast. The nurse explains to the patient that this procedure: Requires recasting after 24 hours. Includes splitting and spreading the cast down the middle to relieve constriction. Includes splitting and spreading the cast on each side and cutting the underlying padding. Should be followed by placing the patient's leg in a dependent position. Bivalving the cast involves full-length splitting of the cast on each side. The underlying padding is also cut, because blood-soaked padding shrinks and can also cause circulatory constriction. After the cast is cut, it is spread sufficiently to relieve constriction. This procedure does not disturb reduction of the bone. The cast is then reapplied (Answer after the swelling has gone down. Answer 2 is the technique used when the cast is removed. The patient's limb should always be elevated (Answer after bivalving, because the underlying condition (edema, i.e., swelling) is best relieved by elevation of the limb, ice packs, and isometric exercises. Look for the best method for relieving pressure. Look at two similar options (#2 and #3) and how they differ ("split and spread down the middle" vs. "on each side"). Note that the word "bivalve" in the question is similar to "split/spread cast in each side" ("bi" = 2; each side = 2 sides). Which statement would the nurse include in teaching regarding nasogastric tubes? Nasogastric tubes should be irrigated with sterile water. Patient should be in a sitting position with head slightly flexed for tube insertion. When resistance is met while irrigating a nasogastric tube, pressure should be increased to complete that irrigation, and the physician should be notified at the completion. Ice chips can be taken as often as desired to promote comfort in the throat. The tube will be inserted with greater ease if the patient is sitting up with head slightly flexed. The tube should be lubricated and will be passed into the stomach with greater accuracy if the patient is given water to drink through a straw; at the same time that the patient is swallowing, the tube is advanced. Answer 1 is not correct because the tube should be irrigated with saline, not water, to prevent electrolyte imbalances. Answer 3 is not correct because pressure must not be used during irrigation. If resistance is met, the physician should be notified immediately. Ice chips (Answer should be used sparingly, not as often as desired, to prevent electrolyte imbalances from excessive hypotonic water ingestion. One choice involves tube insertion; the others involve tube management (although not correct). To correctly instill pilocarpine in a patient's eyes, the nurse should gently pull down the lower lid of the eye and instill the drops: Directly on the central surface of the cornea. On the inner canthus of the eye. Into the conjunctival sac. Directly on the dilated pupil. Eyedrops should be instilled into the conjunctival sac to prevent medication from hitting the sensitive cornea. The patient should then be instructed to close the eye, but not squeeze shut, so that the medication can be distributed evenly over the eye. Answers 1 and 4 are incorrect because instillation on these structures would increase corneal irritation. Answer 2 is incorrect because drops instilled into the inner canthus are likely to run down the outer aspects of the nose or be absorbed systemically through the tear duct. The correct choice is more indirect placement of drops; the other choices are all direct locations. The nurse anticipates that the backbone of treatment for patients with myasthenia gravis will be: Adrenergic drugs. Anticholinergic drugs. Anticholinesterase drugs. Cholinergic drugs. The main treatment for patients with myasthenia gravis is anticholinesterase drugs. These drugs increase the response of muscles to nerve impulses and improve muscle strength by inhibiting the rapid removal of acetylcholine from the myoneural junction. Answer 1 is partially correct, in that adrenergic drugs such as ephedrine sulfate are administered to improve muscle tone but these drugs do not inhibit cholinesterase at the myoneural junction. Likewise, anticholinergic drugs (Answer such as atropine are also used in the treatment of myasthenia, primarily to reduce the incidence of side effects of the anticholinesterase drugs and to reverse their effect if "cholinergic crisis" occurs. Cholinergic drugs (Answer are not indicated in the treatment of myasthenia gravis. Need to know effects of broad drug classes. Clue: two drugs look similar (#2 and #3); #2 is used if there are side effects from #3—the drugs of choice. A patient's burns were treated by the closed method. The burned left leg was cleaned and the left ankle debrided. Mafenide 1% (Sulfamylon) was applied, and the leg was wrapped in fine mesh gauze. Nursing measures when this approach is used include: Cleansing of the wound daily and maintenance of strict isolation to prevent air contamination. Cleansing of the wound daily, or more often if needed, and application of new dressings using clean technique. Cleansing the wound one or more times each day and application of new dressing using sterile technique. Cleansing of the wound daily and utilization of heat lamps to help maintain normal body temperature. Patients with burns limited to an extremity are generally treated by a closed method; that is, wounds are covered with a layer of sterile, fine mesh gauze impregnated with an antibacterial agent such as mafenide 1%. Wounds are cleansed one or more times per day, and dressing are reap plied using strict sterile technique. Patients treated by the closed or semi-open method do not have to be isolated (Answer . Patients treated by the open method (wounds completely exposed to the air) require strict isolation to prevent infection. The open method is usually used for minor burns, areas difficult to dress (burns of trunk, perineum), or new skin grafts. Answer 2 is incorrect because sterile technique must be used. Heat lamp (Answer is incorrect because the wound is covered in the closed method. Two choices are "closed" to the air, and only one uses aseptic technique. The nurse tells a postoperative gastrectomy patient that dumping syndrome is a significant problem for: 70-80% of patients having gastrectomies. 50% of patients having gastrectomies. 25% of patients having gastrectomies. 5-10% of patients having gastrectomies. Although 70-80% of patients having subtotal gastrectomies may experience some symptoms of dumping syndrome, it is a significant problem for only a small percentage (5-10%). The term dumping is used because the symptoms die believed to be due to the rapid emptying of the gastric contents into the small intestine. This produces gastric distention, and some authorities believe that large amounts of extracellular fluid then enter the intestines to dilute the hypertonic stomach contents. The subsequent lowering of the blood volume produces shocklike symptoms, such as weakness, diaphoresis, faintness, and palpitations. Answers 1,2, and 3 are incorrect percentages. Select the smaller percentage; you would remember if most patients develop a "significant" problem. The nurse knows that, in contrast to patients with hypothyroidism, women with hyperthyroidism have: Increased serum cholesterol. Increased basal metabolic rate and serum T3 and T4 Increased serum thyroid-stimulating hormone (TSH). Increased menstrual volume. Patients with hyperthyroidism have an increased basal metabolic rate (BMR) and increased T, and T,. Increased serum cholesterol (Answer , increased TSH (Answer , and increased menstrual volume (Answer are findings consistent with hypothyroidism. Menstruation in hyperthyroidism characteristically is decreased in volume. Cycle lengths may be shortened or prolonged, but eventually amenorrhea develops. Look for an answer with a change in metabolism. Pilocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be: Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid. Impaired vision from decreased aqueous humor production. Constriction of aqueous veins and therefore decreased venous pooling in the eye. Pilocarpine constricts the pupil by causing contraction of the ciliary muscles, thus widening the outflow channels and increasing aqueous flow. Answer 1 is incorrect because pilocarpine is a parasympathomimetic; that is, it mimics the action of acetylcholine at cholinergic nerve endings, thus decreasing pupil size. Answer 3 is incorrect, in that diuretics such as acetazolamide (Diamox), a carbonic anhydrase inhibitor, are used to decrease aqueous production, not pilocarpine. Answer 4 does not describe the actions of any medication used in glaucoma therapy. Look for a choice that would let the pressure "out." Hyponatremia may develop in patients with burns due to: Displacement of sodium in edema fluids and loss through denuded areas of skin. Increased aldosterone secretion. Inadequate fluid replacement. Metabolic acidosis. Hyponatremia, or decreased serum sodium, may develop in patients with burns because sodium tends to move with water into edema fluids and into denuded areas of skin. Answers 2 and 4 are incorrect because both these mechanisms tend to increase sodium reabsorption by the kidney tubules. Inadequate fluid replacement (Answer would tend to mask hyponatremia because of hemoconcentration. Look for the only answer that relates to destruction of skin (longest answer might be a hint). Also, hyponatremia is similar to the word "loss" in the correct option. A patient has had a partial gastrectomy, vagotomy, and gastrojejunostomy. Which complication would the nurse primarily anticipate in this patient's postoperative period? Thrombophlebitis from decreased mobility. Abdominal distention due to air swallowing. Atelectasis due to shallow breathing. Urinary retention due to prolonged use of anticholinergic medications. Patients with high abdominal incisions are prone to atelectasis following surgery because they tend to breathe shallowly to prevent incisional pain. However, the nurse must also institute measures to prevent thrombophlebitis (Answer , wound infection, and dehiscence. Abdominal distention due to air swallowing (Answer is unlikely because the patient has a nasogastric tube in place. Urinary retention after surgery (Answer is generally due to the effects of anesthesia on the autonomic nervous system rather than to the residual effects of anticholinergic medications. Think postoperative pain. Which answer would pain cause? The nurse tells a postoperative gastrectomy patient that the nasogastric tube will be removed: Standard only on the fourth postoperative day. When bowel sounds are established and the patient has passed flatus or stool. Thirty-six hours after the cessation of bloody drainage. After 2 days of alternate clamping and unclamping of the tube. The nasogastric tube is removed after bowel sounds have been reestablished (generally around the third day) and after the patient has passed flatus or stool. Answers 1 and 3 are incorrect because they do not include the return of bowel sounds. Before removal, the tube is frequently clamped for 2-4 hours—not 2 days (Answer —to test the patient's tolerance. Gastric residue is measured after this period. If it is more than 100 ml,, the nasogastric tube is left in place. Like wise, if the patient experiences any pain, nausea, vomiting, or distention during this period, the tube is left in. If no symptoms occur and there is a minimal amount of gastric residue, the tube is removed. The "time" depends on the patient's bowel sounds. Follow the logic: GI surgery, NG tube —> "bowel sounds" (#2). Correct choice is the only one without a specific time. A patient with burns is to receive fluid replacement therapy. Besides assessing size and depth of the burn, which physical parameters are also important baseline data for fluid replacement therapy? Age, sex, and vital signs. Age, weight, vital signs, and skin turgor. Vital signs, level of mentation, and urine output. Vital signs and quantity and specific gravity of urine. Age is important baseline information because IV infusion rates to maintain appropriate quantity and specific gravity of urinary output differ; for example, 10—20 mL/hr for infants versus 50-70 mL/hr for adults. Weight is significant if the Evans or Brooke formula is used for fluid replacement therapy. Both of these formulas use both the size of the burn and the weight of the patient to calculate the amount of fluid to be replaced. Vital signs and skin turgor are both important measures of the degree or extent of hypovolemia. As dehydration develops, skin turgor becomes poor, mucous membranes dry, and the eyeballs feel soft. Likewise, the pulse may become thready and the blood pressure may decrease. Size (weight), as discussed, not sex would determine therapy (Answer 1). Level of mentation (Answer 3) is less helpful in this particular situation because of the fear, pain, and acute anxiety experienced by some patients. Quantity and specific gravity of urine output (Answer 4) are important in assessing the adequacy of fluid replacement rather than as part of the initial assessment. Look for an answer with "body weight." The nurse is to administer the drug of choice for long-term control of generalized tonic-clonic seizures. This drug is: Phenobarbital. Diazepam (Valium). Diphenylhydantoin (Dilantin) sodium. Trimethadione (Tridione). Dilantin (phenytoin, diphenylhydantoin) is consistently found to be effective against most types of seizures except absence seizures. Its precise action is unknown, but it appears to stabilize cell membranes by altering intracellular sodium concentrations. Plasma levels of the drug are checked frequently lo avoid toxicity and to determine effective dosage. Side effects include gastritis and nervousness, and at toxic levels the drug may cause ataxia. Phenobarbital (Answer Is also used in conjunction with diphenylhydantoin. Diazepam (Answer may be used as adjunct therapy in seizure disorders. Trimethadione (Answer 4) is used in the control of absence seizures. "Drug of choice" means first line of * drugs used to decrease seizures (Dilantin decreases seizures). An angiogram was performed using a catheter inserted into the left femoral artery. Which nursing action is the first priority following this procedure? Monitoring vital signs until stable. Frequently checking the puncture site for fresh bleeding, swelling, or increasing tenderness. Measuring the quantity and specific gravity of urinary output. Checking the peripheral pulses distal to the femoral puncture site. After arterial punctures, the first nursing priority is to observe for bleeding or hematoma formation, particularly in the first 4 hours after the procedure. Vital signs (Answer 1) are monitored. The specific gravity and urinary output (Answer 3) are monitored, but this is not as significant as observing the puncture site. The peripheral pulse distal to the puncture site (Answer 4) is also monitored. Because of the size of the vessel, bleeding can quickly cause volume depletion and shock. This is a priority question—look for the choice with the most immediate risk to the patient (bleeding). Which replacement fluid will the nurse least often be expected to administer to a patient with burns within the first 24 hours postburn? Ringer's lactate. Whole blood. Dextran. Dextrose and water. With the exception of the Evans formula, whole blood is administered to patients with burns only when the hematocrit begins to manifest red blood cell loss. Several fluid formulas have been developed to serve as a guideline for fluid replacement in the patient with burns. The Evans formula is the oldest and is based on both the size of the wound and the patient's weight. Colloids (blood, dextran, plasma) and crystalloids (electrolyte solutions) are administered during the first 48 hours. The Brooke formula is similar, except that blood is not given until the hematocrit level has fallen and the need is demonstrated. The Parkland formula is based on the premise that volume expansion is dependent on the rate of infusion rather than the type of replacement. During the first 24 hours, fluid volume is replaced with electrolyte solutions (Ringer's lactate) only (Answer 1). Colloids are used only if urine output is not maintained (Answer 3). During the first or second 24 hours, dextrose and water (Answer 4) are used to maintain fluid volume. Keep in mind the time period: within first 24 hours. Question also asks for least likely choice. With burns, think volume (water) loss is what needs to be replaced, not blood. The nurse must observe for which imbalance to occur with prolonged nasogastric suctioning? Hypernatremia. Hyperkalemia. Metabolic alkalosis. Hypoproteinemia. Removal of gastric secretions incurs the loss of sodium, potassium, and hydrochloric acid ions. The loss of these ions may lead not only to metabolic alkalosis (?H+) but also to hypokalemia. Answers 1 and 2 are incorrect because hypernatremia and hyperkalemia indicate an excess in sodium and potassium ions. Hypoproteinemia (Answer 4) occurs with liver dysfunctions and is not a side effect of nasogastric suctioning. The key word is prolonged. Acid will be lost; therefore, think alkalosis. After left nephrectomy, a patient has a large flank incision. In order to facilitate deep breathing and coughing, the nurse should: Have the patient lie on the unaffected side. Coordinate breathing and coughing exercises with administration of analgesics. Maintain the patient in high Fowler's position. Push fluid administration to loosen respiratory secretions. Because the flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesic administration every 3-4 hours for 24-48 hours after surgery. Therefore turning, coughing, and deep-breathing exercises should be planned to maximize the analgesic effects. The patient may be on either side, as long as drainage tubes are not kinked and gravity flow is uninhibited (Answer . A low Fowler's or semi-Fowler's position is generally more comfortable for the patient and of sufficient height to encourage gravity flow from drainage tubes (Answer 3). Fluid administration is directed toward maintaining blood volume and urinary output (Answer 4). Think patient comfort (analgesics) to reduce patient complications. Note that the words "deep V breathing and coughing" in the stem also are in the correct option (#2). The postoperative nephrectomy patient should be closely observed by the nurse for: Hemorrhage. Hyperkalemia. Respiratory alkalosis and tetany. Polyuria. Hemorrhage may follow nephrectomy because of the difficulty in securing ligatures in the short renal-artery stump. It may occur on the day of surgery or 8-12 days postoperatively, when normal tissue sloughing occurs with healing. Dressing and urine are observed for bright-red bleeding, vital signs are monitored, and the patient is continually observed for any other indications of shock. Hyperkalemia (Answer , tetany (Answer 3), and polyuria (Answer 4) are not common complications after nephrectomy. After any surgery, bleeding is a potential problem. Two days postoperatively, a patient who has had an ileostomy begins to refuse care and repeatedly says to the staff, "Leave me alone, I just want to sleep." What would be the first nursing action? Provide accurate, brief, and reassuring explanations of all procedures. Encourage ambulation in the hall with other patients. Invite a member of an "ostomy club" to visit the patient. Encourage the patient to verbalize his or her feelings, fears, and questions. It is important to recognize that the loss of anatomical integrity initiates a grieving process. Allowing the patient to express feelings of depression, apathy, or disinterest indicates that such feelings are acceptable and not uncommon. Answer 1 is always appropriate and should be consistently carried out; however, in the situation depicted it would follow the verbalization of feelings. Answers 2 and 3 are also alternatives the nurse may wish to employ after assessing the patient's major concerns. First priority—what is concerning the patient? First, feelings. Before insertion of a Miller-Abbott tube, the balloon is tested for patency and capacity and then deflated. Which nursing measure will ease the insertion of the nasoenteric tube? Chilling the tube before insertion. Administering a sedative to reduce anxiety. Warming the tube before insertion. Positioning the patient in low Fowler's position. Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion. The patient may be administered a sedative (Answer on physician's orders to reduce apprehension during insertion. Warming the tube (Answer 3) has no advantages. The patient is usually positioned (Answer 4) in high Fowler's position during insertion to aid in swallowing the tube. Note two contradictory options: "chill" vs. "warm" the tube. Think patient comfort: cold reduces pain. Small, frequent feedings of which type of diet would the nurse recommend for patients experiencing dumping syndrome? Low-protein, high-fat, low-carbohydrate diet. High-protein, high-fat, high-carbohydrate diet. High-protein, high-fat, low-carbohydrate diet. Low-protein, low-fat, high-carbohydrate diet. The symptoms of dumping syndrome are most likely to occur following the ingestion of large amounts of sugars or carbohydrates. Therefore a diet that is high in protein and fats and low in carbohydrates is recommended, to reduce symptomatology and to provide the patient with essential energy requirements. Answers 1 and 4 are incorrect because they do not supply sufficient protein for energy and tissue repair. High protein intake is essential after surgery and most prolonged illnesses for rebuilding tissue. Answers 2 and 4 are incorrect because they list high carbohydrates. Look for foods that slow the movement of food out of the stomach (e.g. ?CHO, ?fat). The nurse recognizes that myasthenia gravis is: An upper motor neuron lesion. A lower motor neuron lesion. A combined upper and lower motor neuron lesion. A genetic dysfunction. Because the dysfunction in myasthenia gravis occurs at the myoneural junction, it is considered a lower motor neuron lesion. Upper motor neuron lesions (Answer involve cranial neurons and their axons in the spinal cord. Combined lesions (Answer 3) generally occur with spinal injury when axons of cranial neurons are destroyed, resulting in hyperreflexia and increased muscle tone below the level of the lesion, and destruction of motor neurons at the level of the injury, which in turn leads to hyporeflexia, decrease muscle tone, and muscle atrophy in those muscles normally innervated by these neurons. Myasthenia gravis is not an inherited disorder (Answer 4). Recent evidence suggests an autoimmune basis. Think of the symptoms—which answer best explains myasthenia gravis? Eliminate #3 and #4. Is it upper or lower motor? The mouth care measure that should be used with caution by the nurse when a patient has a nasogastric tube is: Regularly brushing teeth and tongue with soft brush. Sucking on ice chips to relieve dryness. Occasionally rinsing mouth with a nonastringent substance and massaging gums. Application of lemon juice and glycerine swabs to the lips The patient should be cautioned to limit the number of ice cubes he or she sucks on because the nasogastric suction will remove not only the increased water ingested from the melted cubes but also essential electrolytes. Answers 1,3, and 4 are appropriate mouth care measures for a patient who has a nasogastric tube. One answer is different from the others (teeth, tongue, mouth, gums, lips)—it involves swallowing melted ice. Note the key term with caution. The nurse can expect hyperkalemia to develop following burn damage because there is: Increased exudate formation at the burn site. Disruption of cell membrane integrity, allowing intracellular electrolytes to diffuse into the vascular compartment. Decreased aldosterone secretion, increasing sodium excretion, and retention of potassium. Hyperbilirubinemia secondary to red blood cell destruction. Hyperkalemia (excesses in serum potassium) occurs in burns due to three separate mechanism: (1) cellular injury resulting in the movement of potassium from the intracellular spare into the extracellular space; (2) decreased glomerular filtration and urine output preventing excretion of increased serum potassium; and (3) inadequate tissue metabolism resulting in increased hydrogen ion formation (metabolic acidosis). In the kidney tubules, hydrogen and potassium ions are exchanged for sodium ions. In metabolic acidosis, more hydrogen ions are excreted than potassium ions. Exudate formation itself does not significantly affect serum-potassium levels (Answer 1). During physical and emotional stress, aldosterone levels are increased, thereby lowering serum potassium (Answer 3). Hyperbilirubinemia itself does not affect potassium concentration (Answer 4), though red blood cell destruction probably increases the amount of circulating potassium, because potassium is the major intracellular cation. Look for an answer that describes destruction of tissue or cells ("disruption of cell membrane"). Two days before discharge following a left nephrectomy, a patient expressed renewed concern over the ability to continue many activities with only one kidney. The nurse responds. You seem depressed. Actually you are very lucky, since the pathology reports indicate your tumor was encapsulated. Lots of people do quite well with only one kidney. Would you like mc to call the doctor so you two can discuss it? I can understand your concern, but your remaining kidney is sufficient to maintain normal renal functions. Recognizing the patient's concern is essential both in maintaining rapport and in keeping the lines of communication open. Having done this, the nurse can then assure the patient that one kidney is sufficient to handle renal functions. This statement can then be followed by other discharge instructions, such as the need for adequate fluid intake, avoiding infections, and untoward signs that the patient needs to observe for. Answers 1,2, and 3 do not recognize the patient's concern or facilitate open communication. The best answer acknowledges the patient's concern. Eliminate "call the doctor" (#3) because a nurse can discuss the patient's concerns. Eliminate #1 and #2 because they are trite cliches that close off elaboration. A patient is admitted to the orthopedic unit with a long leg cast, used to immobilize a transverse fracture of the right tibia and fibula. The plaster of paris cast is damp, and the patient is complaining that it feels very hot. The nurse should: Explain to the patient that the cast will feel hot for several hours as the moisture evaporates and the cast hardens. R.ecogni7e that this is a sign of excessive pressure on the soft tissues and notify the physician. Tell the patient not to worry; this is a common complaint. Administer meperidine (Demerol), 50 mg IM, to relieve discomfort. A freshly applied cast generates heat as moisture evaporates and the cast hardens. To facilitate drying, keep it exposed to the air. Do not use plastic covers or Chux on pillows to elevate the limb, because these tend to slow drying. Answer 2 is incorrect; signs of increased pressure are numbness and tingling, pain, and loss of movement. Answer 3 is an inappropriate response to the question because it fails to recognize the patient's cognitive needs. Answer 4 does not take into account that discomfort and apprehension can be reduced if the patient understands what is to be expected. The question asks expected outcome with a new cast. Eliminate #3 because #1 gives the same information without offering a trite cliche. Diagnosis of myasthenia gravis is frequently based on the patient's response to an intravenous injection of edrophonium (Tensilon). If the patient responds positively to this drug, the nurse should expect: Exacerbation of symptomatology. Relief of ptosis but not of weakness in other facial muscles. A prompt and dramatic increase in muscle strength. A slight increase in muscle strength that is countered by an increase in muscle fatigability. Edrophonium (Tensilon) is a short-acting anticholinesterase compound. A positive Tensilon test result (a prompt and dramatic increase in muscle strength) is consist tent with the diagnosis of myasthenia gravis. Answer 1 is incorrect because an exacerbation of symptoms would indicate another cause for the muscle dysfunction. Answer 2 is partially correct: ptosis is relieved, but so is sagging of the other facial muscles. Answer 4 is incorrect because the increase in muscle strength is accompanied by decreased fatigability as long as the drug continues to circulate. Look for improvement as a result. Eliminate "slight" (#4) and partial relief (#2) in favor of "prompt and dramatic." Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range: 5-10 mm Hg. 12-22 mm Hg. 10-20 cm H20. 20-30 mm Hg. The normal range of intraocular pressures is 12-22 mm Hg. Answer 1 is below the range of normal pressures and may occur in hypovolemia (soft eyeballs) or dehydration. Answer 3 is incorrect because ocular pressures are measured in millimeters of mercury. Answer 4 is incorrect because pressures above 22 mm Hg are considered elevated. Watch for the correct unit of measure (mm, not cm). Eliminate too low (#1), too high (#4). Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range: Ask her if she would like her diazepam (Valium). Notify the physician. Ask, "Can you tell me what makes you feel that way?" 0 It is not uncommon for a patient to feel that she will no longer be able to fulfill her role and needs as a woman following a hysterectomy. Verbalization of feelings allows the nurse to assess the patient's coping mechanisms and encourages the patient to deal with her emotional response. Answer 3 is an open-ended question that allows the patient room to respond. Answers 1 and 2 avoid the problem initially. Answer 2 may be appropriate if, after talking to the patient, the nurse assesses that her responses represent a more significant or deep-seated problem. Answer 4 would be appropriate after the patient has aired her feelings. Use therapeutic communication—first, explore patient's comment. Eliminate MD and meds as initial responses. First, focus on feelings! Which behavior is least likely to be included in the nursing assessment of a patient with burns during the recovery period? Anxiety with mild confusion. Desperation and panic. Withdrawal and depression. Dependency and regression. Desperation and panic may strike while the injury is occurring but rarely occur during the recovery period. During the acute stage of burn recovery, anxiety is common due to the stress and pain of injury and dressing changes. Anxiety decreases the individual's ability to perceive situations realistically, which may result in an altered mental state (Answer 1). During the intermediate phase of burn recovery, patients may react to continued pain, changes in body image, and financial stress with various psychological responses, ranging from withdrawal and depression (Answer 3) to acting out anger by refusing to cooperate with the medical regimen and by dependency (Answer 4). Note "least likely" in the stem, meaning "which one is incorrect." Also note time period: during recovery. Forty-eight hours after a nephrectomy, a patient complains of increasing nausea and abdominal pressure. The nurse's first nursing action is to: Change the patient's position to relieve abdominal pressure. Auscultate bowel sounds. Insert a rectal tube to relieve flatus. Administer morphine S04, 6 mg, as ordered for the relief of discomfort. Though nausea may occur following the administration of narcotics, if it is accompanied by the absence of bowel sounds and upper abdominal distention, gastric or small-intestine dilation should be suspected and the nurse's findings reported to the physician. Changing the patient's position (Answer 1) and insertion of a rectal tube (Answer 3) are not helpful if peristalsis is not present (bowel sounds). Administering morphine (Answer 4) is not indicated until the source of the patient's discomfort is diagnosed. Note the time of the event following surgery. What functions should return within 48 hours? Only one option deals with assessment (auscultate); the other three are implementation responses (change, insert, administer). Which instruction would be inappropriate when teaching a patient to use crutches? Use axilla to help carry weight. Use short strides to maintain maximum mobility. Keep feet 6-8 inches apart to provide a wide base for support. If the patient should begin to fall, throw crutches to the side to prevent falling on them. In the use of crutches, all weight bearing should be on the hands. Constant pressure in the axilla from weight bearing can lead to damage of the brachial plexus nerves and produce crutch paralysis. Answers 2,3, and 4 are appropriate instructions to give to the patient preparing for crutch walking. The best answer is the wrong thing to teach. The nurse explains that epileptic seizures or convulsions result from: Excessive exercise with lactic acid accumulation. Excessive, simultaneous, disordered neuronal discharge. Excessive cerebral metabolism, with local K+ increased. Excessive circulating cerebrospinal fluid increasing cerebral pressures. Epileptic seizures or convulsions are the result of excessive, simultaneous, disordered neuronal discharge in the brain. This dysrhythmic electrical discharge may be focal (jacksonian seizure) or widely dispersed (grand mal seizures). Answers 3 and 4 are incorrect because theories for the initiation of these convulsions vary from decreased (Answer 3) intracellular K' to decreased (Answer 4) cerebrospinal fluid to alteration in neuronal defense due to trauma, toxins, or inflammation. Depending on existing potential in the individual, Answer 1 may be a precipitating factor. Look for the key word: "neuronal." What nursing action best facilitates the passage of the nasoenteric tube from the stomach through the pylorus and into the duodenum? Gently advancing the tube 1-4 inches at regular time intervals. Positioning the patient on the right side for 2 hours after insertion. Maintaining strict bed rest and avoiding all unnecessary movement. Positioning the patient in a flat supine position. After the tube has been inserted into the stomach, its movement into the duodenum is first facilitated by having the patient lie on the right side for 2 hours, then on the back with head elevated for 2 hours, and finally on the left side for 2 hours. After the tube has passed the pylorus (this is usually checked by x-ray), ambulating the patient will help move the tube to the point of obstruction. After positioning and ambulation, the physician or the nurse may advance the tube 1-4 inches at specified time intervals (Answer 1) to provide slack for peristaltic action. Remaining quiet or flat in bed (Answers 3 and 4) will not facilitate the advancement of the tube either through the pylorus or through the small intestine. Focus on the two positioning options: right vs. flat supine. Understand the concept of peristalsis and think of the sequence of positioning (right —> supine in semi-Fowler's —> left). During the initial stage of burns, a primary fluid imbalance occurs. The nurse knows that there has been a shift of fluids from: The cell to the interstitial space. The interstitial space into the cell. The interstitial space to the plasma. The plasma to the interstitial space. The hypovolemia that occurs in the initial stage of burns is the result of fluid lost from denuded areas of skin mid edema in and around the burned surface area. Edema formation is due to a shift of plasma fluids to the interstitial space. Answers 1,2, and 3 are incorrect because when tissues are burned, a change in the permeability of both tissue and capillary membranes occurs. This change and increased vasodilation result in a shift of excessively large amounts of extracellular fluid (electrolytes and proteins) into the burned area. Most of this fluid loss occurs deep in the wound, where fluid moves into the deeper tissue. Burns of a highly vascular area (muscle, face) are believed to cause more severe fluid volume shifts than comparable burns to other areas of the body. Where was fluid before the burn? Where would it go after the burn? Note the time period: initial stage. Bed rest is ordered for a patient with chronic glaucoma during a period of acute distress, because activity tends to increase intraocular pressure. Which activity of daily living should this patient be instructed to avoid? Watching television. Brushing teeth and hair. Self-feeding. Passive range-of-motion exercises. Vigorous activities such as brushing the teeth and brushing the hair are generally discouraged during periods of acute distress. These activities tend to increase aqueous production and therefore pressures because they activate sym pathetic nervous system stimulation of the vasculature. Quiet activities such as watching TV (Answer 1), moderate activities such as reading, self-feeding (Answer 3), and passive range-of motion exercises (Answer 4) are encouraged. Look for the activity most likely to increase pressure in the eyes or head. Look for what is not OK because the stem says "to avoid." Three activities are quiet, passive; one is active (brushing). Nursing implications with diphenylhydantoin given during treatment of status epilepticus include giving the intravenous injection slowly and in small increments to prevent: Respiratory depression and/or arrest. Vasodepression and circulatory shock. Irritation and/or necrosis of the vein and surrounding tissue. Vasomotor stimulation, with a sudden, malignant increase in blood pressure. Diphenylhydantoin (phenytoin, Dilantin) must be injected IV slowly and in small increments to prevent vasodepression and circulatory collapse. Respiratory depression (Answer Is generally associated with morphine sulfate. Adrenergic (alpha) drugs such as norepinephrine bitartrate (Levophed) may cause vein and tissue necrosis (Answer 3) and have only rarely caused sudden malignant increases in blood pressure (Answer 4). Know the expected effects of IV Dilantin. Think circulatory. The nurse would be alerted to a sudden increase in intraocular pressure if the patient with open-angle glaucoma complained of: Generalized decrease in peripheral vision over the past year. Difficulty with close vision. Increasing discomfort in the left eye with radiation to the forehead and left temple. Halos around lights. Generally the patient with chronic, or open angle glaucoma has few complaints of intense symptomatology. The usual onset of this condition is slow, silent, and painless. However, some patients experience prodromal symptoms, such as aching and discomfort around the eye, disturbed accommodation to darkness, and blurring of peripheral vision (Answer 1). Any complaint of pain or increasing discomfort with radiation to the forehead and temporal area is a grave sign of a sudden increase in pressure. Difficulty with close vision (Answer 2) is not characteristic of glaucoma. Halos around lights (Answer 4) occur less commonly. Key word is sudden—complaint of eye pain often indicates an acute (sudden) change in intraocular pressure. The nurse will usually ambulate a patient postgastrectomy beginning: The day after surgery. 3-4 days after surgery. After 4 days of bed rest. Immediately after awakening from anesthesia. Patients are ambulated as soon as possible to prevent the complications of bed rest; generally ambulation can begin as soon as 24 hours after surgery. In some instances, such as when the patient is severely debilitated or has complications due to ulcer perforation, bed rest may be prolonged, as in Answers 2 and 3. If this is die case, the nurse will need to observe closely for signs of complications (atelectasis, thrombophlebitis, etc.) and institute measures to prevent them. The patient is rarely if ever gotten up immediately after awakening, as in Answer 4. Look for the best general timing to prevent complications and ensure patient safety. Key term: "usually," meaning typically (not rarely, or under special circumstances). If "cholinergic crisis" is demonstrated in a patient who has myasthenia gravis, all anticholinesterase drugs are withdrawn. To reduce symptoms, which of the following drugs should the nurse be prepared to give? Atropine. Ephedrine sulfate. Potassium chloride. Neostigmine bromide. In cholinergic crisis, all anticholinesterase drugs are withdrawn and atropine (an anticholinergic drug) is given in 2 mg doses IV every hour until signs of atropine toxicity develop (dry mouth, blurred vision, tachycardia, rash or flushing of the skin, and elevated temperature). Answers 2, 3, and 4 are incorrect because they do not act to decrease cholinergic responses. Ephedrine (Answer 2) is used in myasthenia gravis to increase muscle tone; potassium chloride (Answer 3) is used to increase serum K+ because it is believed that adequate serum-potassium levels potentiate the effects of cholinergic drugs; and neostigmine bromide (Answer 4) is an anticholinesterase that acts to improve cholinergic transmission of impulses at the myoneural junction. Look for the antidote (an anticholinergic drug) to counteract untoward effects. Equally important as the depth of tissue destruction in determining severity of burns is the total body surface involved. The nurse would anticipate potential fluid and electrolyte problems when burns are: Superficial partial thickness and cover 20% of the body surface. Deep partial thickness and cover 15% of the body surface. Full thickness and cover 10% of the body surface. Fourth degree and cover 5% of the body surface. Critical burns are classified as deep partial-thickness over 30% of the body or full thickness over 10% of the body. Extensive burns involving the face, hands, and feet or those associated with respiratory injuries are also considered critical. The most frequently used method of calculating the extent of a burn is the "rule of nines." Although this method is fairly simple to apply, it is somewhat inaccurate. This is particularly true when it is applied to children because allowances are not made for the proportional differences in head size and extremity size between children and adults. Hence superficial partial-thickness burns (Answer 1) are not serious unless large areas are involved or the patient is very young or old. Deep partial-thickness burns (Answer 2) are classified as a major burn if over 25% of the body is involved. The fourth degree burn classification is not routinely used (Answer 4). First, eliminate what is least (superficial) and not used (#4).Then, think proportion—greater depth (full thickness) and less area. Patient teaching about glaucoma should include a comparison of the two types. Open-angle, or chronic glaucoma differs from closed-angle or acute glaucoma in that: Open-angle glaucoma occurs less frequently than closed-angle glaucoma. Open-angle glaucoma's symptomatology includes pain, severe headache, nausea, and vomiting; closed-angle glaucoma has a slow, silent, and generally painless onset. The obstruction to aqueous flow in open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma. Open-angle glaucoma rarely occurs in families; however, there is a hereditary predisposition for closed-angle glaucoma. n chronic, or open-angle glaucoma, the obstruction to aqueous outflow is due to degenerative changes in either the trabeculum, Schlemm's canal, or the aqueous veins. Closed angle glaucoma is characterized by obstruction of aqueous outflow due to narrowing of the angle between the anterior chamber and the root of the iris. The other answers are incorrect because chronic, or open-angle, glaucoma occurs more frequently than closed-angle (Answer 1), is characterized by slow, insidious, painless onset rather than the acute symptoms of closed-angle glaucoma (Answer 2), and is certainly familial, if not hereditary (Answer 4). Due to this latter characteristic, family members of patients with open-angle glaucoma should be encouraged to have their intraocular pressure assessed annually, particularly past age 40. Look for similarity between the condition ("open-angle") and clues in the choice that says "does not close," meaning it is open. The question asks how open angle is different. The adequacy of fluid volume replacement in the early postburn period is best reflected by: Blood pressure, pulse rates, and daily weights. Quantity of urinary output and vital signs. Hemoglobin and hematocrit levels. Serum-electrolyte levels and urinary output. Although each of the listed measures can be used to assess the adequacy of the fluid replacement, hourly urine outputs and vital signs provide significant information on fluid balance in the acute burn period. Decreased urine out put, increased pulse rate, and restlessness are early signs of inadequate fluid replacement. Increase in blood pressure, pulse, respirations, and urine output are early signs of circulatory overload. Changes in daily weights provide accurate data over the long run and are extremely important in monitoring fluid volumes in patients on diuretic therapy, such as patients with congestive heart failure or cirrhosis. Answers 1,3, and 4 are not the best indicators. Key words: best and early. Look for indication of adequate volume. Note the two options that include "urinary output," and choose the one that also has vital signs that are vital to assess 4-fluid volume and overload. Which aspect of open-angle glaucoma and its medical treatment is the most frequent cause of patient noncompliance? Loss of mobility due to severe driving restrictions. The painful and insidious progression of this type of glaucoma. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. The frequent nausea and vomiting accompanying use of miotic drugs. The most frequent cause of noncompliance to the medical treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the patient's ability to read for extended periods, and making participation in games with fast-moving objects impossible. Answer 1 is incorrect because daytime driving is not restricted. Answer 2 is incorrect because this process is painless. The fact that the process is painless and insidious may in fact increase patients' non compliance because they do not usually experience any adverse reactions if they do not instill their eyedrops. Nausea and vomiting are rare toxic effects of pilocarpine and are usually very mild; hence Answer 4 is incorrect. Try KIS—Keep it simple: glaucoma is a problem with vision; hence, "decreased . . . vision" in #3 looks good. In addition, the stem mentions "medical treatment"; pilocarpine is a specific drug mentioned in #3. Recognize expected effects of miotics. Which would the nurse expect to see with the dumping syndrome? Feeling of hunger. Constipation. Increased strength. Diaphoresis. Profuse perspiration, diaphoresis, is one of a group of symptoms that happen 5-30 minutes after a high-carbohydrate meal or when liquid is taken with the meal. This is caused by entrance of food into the jejunum before it has had a chance to begin the digestive process. Other symptoms include a feeling of fullness, not hunger (Answer 1); diarrhea, not constipation (Answer 2); and weakness, not increased strength (Answer 3). Stem asks what would the nurse see (objective). Three choices are subjective. Choose the one that is different. The nurse observes a patient in the orthopedic clinic using a long pencil to scratch the skin under the cast. The nurse should: Ask the physician for an oral medication order to relieve itching. Explain to the patient that scratching under the cast should be avoided, because it may break the skin and cause an infection. Assist the patient by gently rolling the casted leg in the palmar surfaces of the nurse's hands. Take the pencil away from the patient. It is not safe to insert any foreign object under a cast, because the skin may break and become infected. Scratching also disturbs the padded surface under the cast, causing it to become wrinkled, which may lead to skin irritation and breakdown. Itching under the cast can be relieved by directing air (from a blower) under the cast. Oral medication is not generally effective in relieving this type of skin irritation (Answer 1). Rolling the cast (Answer 3) while the patient scratched would only increase the risk of skin damage. Taking the pencil from the patient (Answer 4) would deny his nr her ability both to understand the rationale and to take responsibility for actions. Patient safety is a priority (reduce risk of damage to skin). The best explanation for the nurse to offer to a patient and family would be that myasthenia gravis is a: Degenerative dysfunction of the basal ganglia. Transmission dysfunction at the myoneural junction. Hypertrophic reaction in the anterior motor neurons of the spinal cord. Hereditary condition of cranial nerves VII, IX, and X. The primary dysfunction in myasthenia gravis occurs at the myoneural junction (the synapse between the end of a myelinated nerve fiber and a skeletal muscle fiber). Normally, acetylcholine is secreted by the nerve ending, which counts on the muscle fiber membrane by increasing its permeability to sodium. If sufficient sodium enters the muscle fiber membrane, an action potential is promulgated and causes the muscle fiber to contract. To enable the muscle fiber to repolarize, the acetylcholine in the synaptic junction is destroyed by cholinesterase. In myasthenia gravis, these normal impulses are blocked at the myoneural junction. Answer 1 is incorrect because degeneration of the basal ganglia results in increased muscle tone, as occurs with Parkinson's disease. Answer 3 is incorrect because increased stimulation of muscle fibers by anterior motor neurons would also increase muscle contractions. Answer 4 is partially correct, in that there does seem to be a familial tendency toward the development of myasthenia; however, if myasthenia is generalized, it usually affects not only racial and mastication muscles but also ocular movement (diplopia and ptosis), as well as muscles of the neck, trunk (respirations), and limbs. Look for clues—myo (muscle); neural (nerve). Major problem is muscle weakness. Fifty-four hours after a patient sustained deep partial thickness burns of the left leg and thigh, the patient's urine output increased from 1000 to 2300 mL/24 hr. Laboratory values were as follows: serum sodium, 136 mEq/L; serum potassium, 4 mEq/L; and hematocrit, 34%. The nurse knows that the changes in the patient's urinary output and lab studies indicate: Beginning of the interstitial-to-plasma fluid shift phase of burns. Kidney failure. Circulatory overload due to rapid IV infusion rate. Hyponatremia. The diuretic stage of burns occurs 48-72 hours alter injury. The fluid shift is the opposite of that in the initial stage. Fluids, electrolytes, and proteins may move very rapidly from the interstitial space back into the vascular compartment. Unless renal damage has occurred and there is no indication (Answer 2), diuresis ensues, due to the increased blood volume and renal blood flow. Serum electrolytes and hematocrit are decreased due to hemodilution. If urine output is insufficient at this time, symptoms of circulatory overload and cardiac failure will occur. There are no data to support Answer 3. The sodium value is within normal limits (Answer 4). Clue: time frame—after the initial phase (54 hours). Think expected changes over time in fluid balance (major shifts). Recognize normal serum Na+ value and eliminate #4. With increased output, you can eliminate #2 and #3. A nursing care plan includes observing for the most common patient problems arising from the use of pyridostigmine (Mestinon) and neostigmine bromide (Prostigmin), which include: Gastric distressùnausea, anorexia, diarrhea. Elimination problemsùurinary retention. Central nervous system excitationùflushing, irritability. Cardiac arrhythmiasùpalpitations, PVCs. The most common side effects of pyridostigmine (Mestinon) and neostigmine bromide (Prostigmin) include anorexia, nausea, diarrhea, and abdominal cramps. These symptoms are due to increased gastrointestinal secretions, smooth-muscle contractions (peristalsis), and irritation of the gastric mucosa. Answer 2 is incorrect because increased cholinergic discharge increases bladder tone and contraction, thus facilitating voiding. Answers 3 and 4 are incorrect because the symptoms listed are consistent with increased adrenergic, not cholinergic, discharge or stimulation. Need to know expected common outcomes. Think GI system: nausea is a common side effect with many drugs. Other options are more severe. Before discharge a postoperative gastrectomy patient asks the nurse pointedly, "How long will it be before I can eat three meals a day like the rest of my family?" The nurse responds: Eating six meals a day can be a bother, can't it? Some patients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you. You will probably have to eat six meals a day for the rest of your life. It varies from patient to patient, but generally in 6ù12 months most patients can return to their previous meal patterns. In response to direct questioning by the patient, the nurse needs to provide brief, accurate information. Some patients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of patients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal. Answer 1 is incorrect because it does not answer the question. Answer 2 is correct as far as it goes, but still does not answer the patient's question. If the nurse does not know the answer to a question, he or she should admit it but try to get the information. Answer 3 is incorrect because it gives inaccurate information. The correct choice answers what the patient asked; #2 and #4 are similar, but #4 gives more specific information (6-12 months as opposed to "a little longer"). The nurse would be correct in saying that two common causes of primary hypothyroidism are: Destruction of thyroid tissue by radioactive iodine during therapy for hyperthyroidism, and spontaneous atrophy due to autoimmune response. Spontaneous atrophy due to autoimmune response, and surgical removal of the thyroid gland. Surgical removal of the thyroid gland, and tumors of the pituitary gland that decrease the amount of circulating thyroxine. Tumors of the pituitary gland, and/or large doses of antithyroid drugs. The most common cause of hypothyroidism is excess thyroid tissue destruction due to radioactive iodine therapy for hyperthyroidism. Spontaneous hypothyroidism is believed to be due to an autoimmune response. Several studies have revealed a high incidence of antibodies for thyroid antigen in patients with spontaneous atrophy (Answer 2). Other, less common causes include surgical removal (Answer 3), Hashimoto's thyroiditis, overuse of antithyroid drugs (Answer 4), and pituitary tumors or insufficiency that decrease the circulating levels of thyroid-stimulating hormone. Use a process of elimination and keep two common causes in mind. In order to take full advantage of the effects of pyridostigmine bromide and neostigmine bromide in reducing dysphagia related to myasthenia gravis, the nurse should plan to give the medications before meals. How long before? 2 hours. 45-60 minutes. 20-30 minutes. 10-15 minutes. In order to take full advantage of the effects of anti cholinesterase drugs, they should generally be scheduled 20-30 minutes before eating. Answers 1 and 2 are not totally incorrect, in that these drugs generally act over a 3-hour period; however, peak action occurs quickly, and patients with dysphagia need time to eat, chew, and swallow during meals. Rushing at meals causes unnecessary fatigue. Answer 4 may not allow enough time for the drug to take effect. Clue: time frame. First, eliminate the extremes (#1, #4); look for a midpoint. Most drugs take effect within 30 min. What is the desired outcome? Improve swallowing of food. A patient recuperating from burns is withdrawn and depressed. The nurse can expect this patient to exhibit such psychological reactions during the recuperative stage because of: Pain and immobility. Changes in body image. Financial concerns. Anger. Body image changes are the most frequent basis for psychological responses during the recuperative phase. This is particularly true if the patient is young or has sustained facial or neck burns. Also, self-esteem is often lowered. The patient needs to be encouraged to talk about the perceived changes between what he or she was, and what he or she is now. Sessions with a psychiatric nurse specialist may be helpful. Occasionally individual or group therapy is indicated. Pain and immobility (Answer 1) create problems in the acute phase of burns. Financial concerns (Answer 3) may affect responses during the recuperative phase, but they are not a significant concern for all patients. Anger (Answer 4) may be a response during each phase as the patient reacts to various real and imagined losses. Clue: time frame ("recuperative stage"), not acute stage. The reality of disfigurement fits the time period. Because medications have been increased for a patient with myasthenia gravis, it is important that the nurse observe for signs of "cholinergic crisis." These include: Dilated pupils, profuse diaphoresis, and trembling. Constricted pupils, hypersalivation, and hypotension. Dilated pupils, nausea, and tachycardia. Constricted pupils, dry mucous membranes, and bradycardia. Signs of "cholinergic crisis" include pupils constricted to less than 2 mm, severe diarrhea, nausea, vomiting, hypersalivation, lacrimation, pallor, and hypotension. Bradycardia may occur but is uncommon. In severe cases, confusion progressing to coma may occur due to blockage of cerebral synapses. Answers 1 and 3 are symptoms related lo increased adrenergic discharge. Answer 4 is only partially correct. The "eyes" have it! First decide that constricted pupils occur (this means that #1 and #5 are eliminated). The expected effects of too much medication in this condition would eliminate #4 (not dry mucous membranes, but hypersalivation). The nursing assessment of a patient recently diagnosed with hypothyroidism will likely reveal the most common clinical manifestations of hypothyroidism, which are: Increased body temperature, tachycardia, and fatigue. Decreased exercise tolerance and facial and pitting edema. Increased sluggishness, increased cold intolerance, and puffy eyelids, hands, and feet. Decreased facial expression, diarrhea, and weight gain. A deficiency of thyroid hormone causes widespread metabolic changes. Alterations in fluid and electrolyte balance due to increased capillary permeability lead to fluid retention that results in edema, particularly of the eyelids, hands, and feet. Answer 1 is ncorrect because the lowered metabolic rate decreases cellular oxygen consumption; as a result, the heart rate, pulse pressure, and blood pressure are educed. Answer 2 is ncorrect because there is eyelid edema, not facial edema. The basal metabolic rate is educed, causing symptoms of anorexia, constipation, and intolerance to cold due to a lowered body temperature. Answer 4 is incorrect because it includes diarrhea. Reduced cerebral blood flow affects both perception and coordination and results in symptoms of lethargy, generalized weakness, and slowing of both intellectual and motor functions. Note hypo (I), not hyper (T). Associate metabolic changes with the thyroid. Increased (T) sluggishness (#3) really means slow down (4-). In contrast to hypothyroidism, hyperthyroidism is due to excessive levels of thyroxine in the plasma. Clinical data gathered by the nurse indicating this endocrine dysfunction would include: Systolic hypertension and heat intolerance. Diastolic hypertension and widened pulse pressure. Heat intolerance and weight gain. Emotional hyperexcitability and anorexia. The patient with hyperthyroidism has an increased metabolic rate due to excess serum thyroxine leading to symptoms of systolic hypertension, heat intolerance, widened pulse pressure, and emotional excitability. Answer 2 is incorrect because the diastolic blood pressure reduces due to decreased peripheral resistance. Weight loss (not gain, as in Answer 3) occurs because of increased catabolism despite an increase in appetite. Anorexia in Answer 4 is incorrect because the patient has increased appetite. Note hyper—metabolism speeds up. Three options have both a correct and an incorrect element. Look for the option in which both parts are correct (#1). Which statement by the nurse about myasthenia gravis is accurate? Thymectomies rarely produce remissions in myasthenia gravis. Myasthenia gravis is an acute illness that progresses rapidly. Myasthenia gravis has increased muscle strength as a major symptom. Myasthenia gravis may be an autoimmune disease. Myasthenia gravis is a rare disease of unknown cause but is suspected to have autoimmune characteristics. Answer 1 is not correct because thymectomy has often resulted in remission or improvement (in approximately 70% of patients), not rarely. Answer 2 is not correct because myasthenia gravis runs a chronic and progressive, not acute and rapid course. One of the major symptoms is muscle weakness, not increased strength (Answer 3). Use process of elimination, with a true-or-false approach as you look at key words in the options: rarely, acute, increased muscle strength. Which nursing intervention would be included in the preoperative period for a patient who will have a partial gastrectomy, vagotomy, and gastrojejunostomy? Insertion of a nasogastric tube before surgery. Administration of diazepam (Valium), 4 mg, with 4 oz water 1 hour before surgery. Detailed description of the possible complications that could happen postoperatively Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency. A nasogastric tube will be inserted early on the surgical day to monitor GI contents. Answer 2 is not correct because the patient will not be allowed anything by mouth; all medications will be administered by injection in the immediate preoperative period. Answer 3 is not correct because, although it is important for the physician (not a nursing intervention) to explain possible complications when obtaining permission to perform the surgery, the timing is inappropriate for any lengthy descriptions of possible complications. Answer 4 is not a good choice because the patient should be encouraged, not discouraged, to take an appropriate amount of pain medications so he or she will be able to cough, turn, and deep breathe to avoid respiratory complications. Choose the best answer to present complication during or after surgery. Clue: because it is gastric J surgery; look at the option that has "nasogastric tube." Both Cushing's syndrome and Addison's disease are due to dysfunction of the adrenal cortex. In order to plan for the care of a patient with Cushing's syndrome, the nurse should know that the primary pathology is: Increased Cortisol secretion. Increased epinephrine secretion. Decreased aldosterone secretion. Decreased ACTH secretion. The primary pathology in Cushing's syndrome is increased scrum Cortisol, which acts to accelerate the rate of gluconeogenesis in the body, thus mobilizing stored fats and proteins. Serum glucose is increased, stimulating insulin secretion by the pancreas and resulting in abnormalities in fat metabolism and deposition. Weight gain is common; the torso enlarges and fat pads develop on the back of the neck and in the cheeks, giving the patient the characteristic "buffalo hump" and "moon fades." Increased epinephrine secretion (Answer 2) is associated with pheochromocytoma. Increased aldosterone Answer 3 is associated with primary aldosteronism. Decreased ACTH secretion (Answer 4) is associated with dysfunctions of the pituitary gland. Cushing's and Cortisol both start with C. Because Cortisol is a glucocorticoid, the nurse caring for the patient with Cushing's syndrome should expect: Hypoglycemia due to increased insulin production. Skeletal-muscle wasting because glucocorticoids promote protein and fat mobilization. Dependent edema and severe hypokalemia due to abnormal aldosterone secretion. Discoloration or hyperpigmentation of the skin due to increased pituitary secretion of ACTH. Lassitude and muscle weakness are early clinical signs of Cushing's syndrome. Catabolism from gluconeogenesis occasionally results in a marked decrease in skeletal mass, and the patient's extremities may appear wasted. Answer 1 is incorrect because gluconeogenesis from excess Cortisol secretion results in hyperglycemia. Answer 3 is partially correct: hypersecretion of aldosterone in Cushing's disease is rare; however, large quantities of Cortisol tend to increase sodium and water retention and potassium excretion. Edema and hypokalemia occur only in severe cases. Discoloration and hyperpigmentation (Answer 4) occur with adrenal insufficiency. Visualize the patient with Cushing's— skinny legs (wasting) and buffalo hump (fat mobilization). In Addison's disease, glucocorticoids, mineralocorticoids, and androgenic hormones are all reduced. Therefore, in contrast to Cushing's syndrome, the nurse should expect to find: Hypotension, weight loss, and physical and mental exhaustion. Hypertension, moon facies, and masculinization in women. Hypotension, hyperglycemia, and weight gain. Hypertension, male impotency, and menstrual disturbances. Signs and symptoms of Addison's disease include hypotension, hypoglycemia, muscular weakness, fatigue, weight loss, hyperkalemia, and depression. These symptoms are primarily due to disturbances in sodium, water, and potassium imbalances that cause severe dehydration. Answer 2 includes symptoms of Cushing's syndrome. Answer 3 is incorrect because hyperglycemia and weight gain are consistent also with Cushing's Syndrome. Answer 4 also includes symptoms of Cushing's syndrome. Look for signs of a deficiency (hypo, weight loss, ? energy). If one part of an option is incorrect, the entire option is incorrect (e.g., weight gain in #3 makes the entire option incorrect, although hypotension is correct). Iron deficiency anemia is best described as: Hypochromic microcytic. Hyperchromic macrocytic. Hyperchromic microcytic. Hypochromic macrocytic. Iron deficiency anemia is characterized by a decrease in red blood cell color due to a decrease in iron (hypochromic) and an increase in immature red blood cells (microcytic) Answer 2 describes the red blood cells in pernicious anemia. Answers 3and 4 describe no particular conditions. Look for similar meanings in stem and v" answer—deficiency in the stem, and hypo and micro in the correct option (#1). The nurse should expect that a patient's emotional responses to acute rheumatoid arthritis would primarily depend on the patient's: Self-concept, body image, and usual effective coping strategies. Relationship with the patient's mother. Usual effective or palliative coping strategies only. Economic status and work history. In assessing any patient's emotional responses, the nurse should first assess the patient's ego strength, body image, and coping abilities for life situations in general. The manner in which the patient views himself or herself will greatly affect attitudes toward disease and emotional response. If the patient normally denies or represses threatening information or situations, desirable outcomes may be difficult to achieve. Research indicates that social supports are extremely important in maintaining health. The relationship between the patient and the patient's mother (Answer 2) should be assessed. However, if the patient has a strong self-image, the issues between mother and adult child should be resolvable either alone or with objective outside help. Answer 3 is incomplete. Economic status and work history (Answer 4), depending on their value to the patient, may not be important determinants of emotional response. Select the broadest, most inclusive answer that covers them all. When in doubt about the best psychosocial option, choose the "self-image, self-concept" type of answer. Because aldosterone is the major mineralocorticoid secreted by the adrenal cortex, which fluid and electrolyte imbalance should the nurse anticipate with decreased secretion of this hormone? Hyperkalemia. Hypernatremia. Hypervolemia. Hypercalcemia. The primary fluid and electrolyte imbalances in Addison's disease are hyponatremia, hypovolemia, and hyperkalemia. These imbalances are caused by decreased aldosterone secretion. Answers 2 and 3 are incorrect because they occur with excessive secretion of this hormone. Calcium levels are not affected by this condition (Answer 4). Need to know relationship with sodium (4) and potassium (T). Key word is decreased aldosterone secretion. The care plan for a patient who is burned includes observing for side effects of mafenide 1% (Sulfamylon), such as: Severe electrolyte disturbances. Metabolic acidosis. Metabolic alkalosis. Staining of linen. Mafenide 1% (Sulfamylon) is a white antibacterial ointment applied once or twice daily. Besides causing pain on application, this medication is a carbonic anhydrase inhibitor that interferes with the kidney's ability to excrete hydrogen ions and thus may cause metabolic acidosis, not metabolic alkosis (Answer 3). Patients who are treated with mafenide 1% need to have their acid base balance monitored by blood gas determinations. Clinical signs of metabolic acidosis are increased rate and depth of respirations. Silver nitrate causes black discoloration of linens, and its hypotonicity causes electrolyte imbalances (Answers 1 and 4). Patients treated with silver nitrate need supplemental sodium, potassium, and chloride. Recognize expected desired and untoward metabolic effects. This eliminates #1; #4 is a side effect of a different drug. A patient complains of not having had a bowel movement since being admitted 2 days ago for multiple fractures of both lower legs. The patient is on bed rest and skeletal traction. Which intervention would be the most appropriate nursing action? Administer an enema. Put the patient on the bedpan every 2 hours. Ensure maximum fluid intake (3000 mL/day). Perform range-of-motion exercises to all extremities. The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted. Answer 1 is incorrect because this may not be necessary and also requires a doctor's order. Answer 2 is incorrect because this is a great deal of exertion when die patient is not expressing an urge to defecate. Although activity usually helps bowel evacuation, it would be impossible to exercise extremities that have unhealed fractures (Answer 4). Priority nursing action is to prevent and v correct constipation: T fluids —> ? fecal movement. Which cardinal sign heralds the onset of thyroid storm? Fever. Tachycardia. Hypertension. Tremulousness. Thyroid storm may be precipitated by a number of stresses, such as infection, real or threatened loss of a loved one, or thyroid surgery undertaken before the patient was prepared adequately with antithyroid drugs. A change heralding thyroid storm is a fever: the patient's temperature may rise as high as 106'F (41"C). Answers 2,3, and 4 are symptoms of hyperthyroidism and become exaggerated during thyroid storm. Without treatment, the patient progresses from delirium to coma; death ensues as the result of heart failure. Key word is cardinal—most important; what you will note first. The nurse would recognize drainage of blood from the nasogastric tube after gastrectomy surgery as abnormal if: It continued for 4-6 hours. It continued for a period longer than 12 hours. It turned greenish yellow in less than 24 hours. It was dark red in the immediate postoperative period. Bloody drainage from the nasogastric tube more than 12 hours after surgery should be considered unusual and reported to the surgeon. Prolonged bleeding may be indicative of a slow bleeder, a blood dyscrasia, or problems with incisional closure. Any of these may increase blood loss and lead to shock. Answers 1,3, and 4 are incorrect because they are normal findings in the early postgastrectomy period. The key element is a time factor, not color (i.e., not greenish-yellow, red). Choose an answer indicating the greatest risk to the patient (prolonged bleeding). Fluid therapy postburn may necessitate as much as 7 liters of fluid in 24 hours for a 70 kg individual. Using a 15 gtt/mL administration set, the drops per minute that the nurse would set to deliver this volume would be: 48 gtt/min. 75 gtt/min. 60 gtt/min. 90 gtt/min. Calculating the correct rate requires computation of the hourly volume (290 mL) and the minute volume (5 mL), and then multiplying the rate, in mL/min, by the drop factor (15 gtt/mL). (The hourly and minute volumes have been rounded to the nearest whole number.) Answers 1 and 3 are not fast enough to deliver this large a volume in the prescribed period. Answer 4 is too rapid. A quick method of computing the drip ate s to use the first two numbers in the 24-hour fluid volume, i.e., 7000 mL in 24 hours = 70 gtt/min. This shortcut may be useful when initially starting an infusion, before mathematically calculating the rate. Use only with 15 gtt/mL factor. Use basic IV calculation. Eliminate the extremes (#1 and #3 are too slow; #4 is too fast); select the midpoint here. The nurse anticipates that osteoporosis may result from prolonged immobilization because of: Lack of weight bearing, which decreases osteoblastic activity. Decreased dietary calcium intake. Deposition of excess calcium phosphate salts. Lack of weight bearing, which increases bone formation. Osteoblastic activity (bone growth) requires the stress and strain of weight bearing to be proportional to osteoclas tic activity (hone breakdown). When the patient is immobilized for an extended period of time, bone breakdown takes place. Although dietary intake is important, it is not recommended that there be an increase in calcium intake (Answer 2) due to the potential for kidney stones as a result of immobilization. Osteoporosis is related to a deficit of calcium, not an excess (Answer 3). Bone growth is dependent on weight bearing, not lack of it (Answer 4). Focus on two options with "lack of weight bearing." Recognize expected outcome of immobilization—look for loss of bone density. The nurse knows that in a patient who has deep partial or full-thickness burns, the hematocrit is reduced due to: Lack of erythropoietin factor. Hemodilution and volume overload. Metabolic acidosis. Hypoalbuminemia. Hematocrit is reduced due to hemodilution and volume overload resulting from the interstitial-to-plasma fluid shift. Erythropoietin factor (Answer 1) is produced by the kidneys and would only be reduced //there were kidney failure. Metabolic acidosis (Answer 3) does increase red blood cell fragility, but it is not applicable in this situation. Hypoalbuminemia (Answer 4) causes loss of oncotic pressures in the vascular compartment. The primary effect of this phenomenon is movement of fluid from the vascular compartment to the interstitial space, the outcome of which is hemoconcentration. Read answers to find clues—low hematocrit and hemodilution. Following gastrectomy surgery the nurse must observe for signs of pernicious anemia, which may be a problem after gastrectomy because: The extrinsic factor is produced in the stomach. The extrinsic factor is absorbed in the antral portion of the stomach. The intrinsic factor is produced in the stomach. Decreased hydrochloric acid production inhibits vitamin B12 reabsorption. Pernicious anemia may occur following subtotal gastrectomy (when large portions of the stomach are removed) due to the loss of tissue that produces the intrinsic factor. Loss of this factor necessitates the parenteral administration of vitamin B, „ the extrinsic factor. Answer 1 is incorrect because the extrinsic factor is found in food. Answers 2 and 4 are incorrect because it is the loss of intrinsic factor that results in the malabsorption of vitamin B,,. Note the pattern in the responses: two extrinsic factors, one intrinsic; choose the one that is different. Need to know reason for expected problem. Which nursing intervention can aid in reducing the gastric side effects of pyridostigmine bromide (Mestinon) and neostigmine bromide (Prostigmin)? Give with milk, soda crackers, or antacids. Push fluids and encourage ambulation. Keep room cool and discourage visitors. Encourage food high in potassium. The gastric distress that occurs as a side effect of these medications can be reduced by administering the drugs along with milk, soda crackers, or antacids. The nursing actions in Answer 2 are consistent with elimination problems (urinary retention); those in Answer 3 are consistent with central nervous system excitation (flushing, irritability); and the action in Answer 4 is consistent with cardiac arrhythmias (palpitations, PVCs). Relate the system affected (GI) to the v' intervention (food). The nurse would recognize a generalized tonic-clonic seizure if which of the following occurred? Brief, abrupt loss of consciousness lasting 10-20 seconds. Loss of consciousness for several minutes, with sustained and intermittent contractions of all motor muscle groups. Sustained and intermittent contractions of selected motor groups in a somewhat confined area. Twitching of facial muscles. Generalized tonic-clonic (grand mal) seizures are characterized by auras preceding the convulsive spasms of all muscle groups, loss of consciousness, and loss of sphincter control. Brief, abrupt loss of consciousness, with a characteristic "blank stare," is indicative of absence (petit mal) seizures (Answer 1). Focal or partial seizures usually involve only a portion of the brain and reflect the area of the brain activated by abnormal discharge (such as tonic and clonic contractions of the large muscles in an arm or leg) (Answer 3). Localized twitching of facial muscles, especially of the angle of the mouth, or within a finger or toe, is characteristic of a jacksonian seizure (Answer 4). Look at "minutes" vs. "seconds"; "generalized" in the stem goes with the longer time period. Look for key words in stem and answer—"generalized" and "all motor muscle groups." When testing the sensory response of a 75-year-old patient to dull or sharp objects, which finding would be considered normal? The patient is: Able to identify location of touch correctly but not the type of sensation. Able to identify type of sensation correctly but not the location. Able to identify both type and location correctly, but the response is slow. Unable to identify sensation in any area. The speed (velocity) of nerve impulses decreases with aging, making responses slower. The amount of change varies with individuals, so a specific change according to age is not predictable (Answers 1 and 2). Sensory conduction decreases faster over time compared with motor conduction; some areas are less sensitive (ankle malleolus), but the change is not generalized throughout the body (Answer 4). The key word in the stem is "normal," and the correct choice must apply to all older adults. Choose the most inclusive Answer: #3 includes #1 and #2. A patient is awaiting surgery for reduction of a fractured right femur. Skeletal traction has been applied. Which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome for the patient? Risk for impaired skin integrity. Pain (acute). Impaired physical mobility. Risk for fracture deformity. Pain management requires the nurse and physician to collaborate to achieve optimal relief for the patient. The use of analgesics for pain requires a physician's order. The nurse assesses the patient's response to drug therapy and alerts the MD to needed changes. The nurse may also recommend nondrug interventions to promote patient comfort (progressive relaxation, massage). Answers 1 and 3 are manageable by independent nursing actions—careful assessment, ROM, proper positioning. Answer 4 is not a nursing diagnosis, but a medical problem to be corrected by surgery. The key words in the stem are best outcome and collaboratively. Although independent nursing actions could be planned for each option, look for the one that requires physician's orders to implement care. Most adverse drug effects in the elderly occur because: The amount of body water is decreased. Hormone activity is generally diminished. The amount of body fat tends to increase with age. CNS effects decrease in the elderly. There is an increase in body fat and a decrease in lean muscle mass, which increases the duration of drug effects. There is a decrease in the percentage of body water (Answer 1) in the elderly; however, it is the changes in the kidney that affect drug excretion, resulting in drug toxicity. Enzymes in the liver, not hormones (Answer 2) are diminished, which affects the metabolism of drugs. The CNS effects (Answer 4) are usually increased in the elderly because of problems with drug accumulation, duration of effects, and toxicity. Eliminate the options that are not true first (#2, #4). Know normal processes of drug metabolism regardless of age. Which nursing diagnosis would be the priority in the care of a patient with acquired immunodeficiency syndrome (AIDS)? Impaired skin integrity. Anxiety (death). Pain (acute). Ineffective breathing pattern. All of the diagnoses are problems in the AIDS patient. Providing optimum pain management and keeping the patient comfortable must be a priority, particularly over skin integrity (Answer 1). Pain control will also have an impact on patient anxiety (Answer 2) and breathing (Answer 4). When all the answers are correct, use Maslow's hierarchy to establish priorities. With three good choices, choose the one that could cover two other options (#3 covers #2 and #4). Which of the following is most important to include in teaching a patient about preventing heat cramps when working outside in hot weather? Prior history of heat sensitivity. Need to maintain sodium level in body. Importance of drinking fluids to stay cool. Risk of potassium and magnesium loss. Heat cramps occur when fluids are lost through excessive sweating and water is replaced without sodium replacement. A balanced solution or sources of water and sodium should be ingested. Sodium chloride tablets may be taken, but they may cause stomach irritation. If there was a prior history (Answer 1) and another admission, there is still a need for patient teaching. Answers 3 and 4 are not incorrect; fluids are important for evaporative cooling, and potassium and magnesium may he lost, hut the role of sodium is most important to prevent future problems. The stem asks for the most important. When all of the options are correct, use a process of elimination to select the one that will make the greatest difference— prevent harm (#2)—or incorporates other options. Which signs and symptoms indicate that the patient is experiencing hypovolemic shock? Increased heart rate and decreased urine output. Decreased urine output and pitting edema. Fever and furrowed tongue. Bounding pulse and crackles in the chest. Tachycardia and urine output less than 30 mL per hour are classic indicators of low circulating volume—hypovolemic shock. Both the cardiac and renal systems are compensating for the low perfusion state. Answer 2 is partially correct; pitting edema, however, is seen with fluid retention and volume excess. Answer 3 indicates dehydration, also a state of fluid deficit, but the signs would not be classic of shock. Answer 4 describes a state of fluid volume excess. Turn each option into a true-or-false question: e.g., would a patient in shock have an increased pulse? True? Or false? Which sign is the best indicator of early infection in a patient who is immunosuppressed? Fever. Sore throat. Elevated sedimentation rate. Decreased urine output. In a patient who is immune-suppressed, the oral mucous membranes are often a source of infection; therefore, a com plaint of a sore throat is an important early indication of a potential problem. With immunosuppression the body is often unable to respond to an infection with the characteristic indicators, such as a fever (Answer 1). The drugs used to suppress the immune system mask the signs of infection (Answer 3). Answer 4 is not a sign of infection. The key word is early. Know the concept of immunosuppression and what this may affect (e.g., mask some infections, reduce ability to fight infection with fever, allow opportunistic infections to take hold [mucous membranes]). The most important information to include when teaching a patient who is being discharged on continuous ambulatory peritoneal dialysis (CAPD) would be the need to: Use sterile technique to prevent infection. Increase protein in the diet. Record blood pressure and weight daily. Wear a medical identification bracelet. Peritonitis is the most serious complication of CAPD. How to maintain aseptic or sterile technique to prevent bacteria from entering the peritoneal cavity is the most important information to teach the patient. Answer 2,3, and 4 are also important to teach the CAPD patient after the nurse determines that the patient will be able to safely perform sterile technique. This is a "rank order of priority" question. When all of the options are correct, which one prevents the patient from the greatest potential risk? A patient complaining of severe indigestion while walking in the hall, grabs his chest and falls to the floor. The first assessment to make would be to determine: Unresponsiveness. Breathing pattern. Blood pressure. Presence of a pulse. A witnessed or unwitnessed cardiac arrest starts with establishing the state of consciousness of the patient. It is important to determine if the patient is awake before proceeding with emergency CPR. Answers 2 and 4 are the next steps in initiating CPR. Answer 3, although not part of the ABCs of CPR, would be done after establishing a pulse. This is a "rank order of priority" question. Remember "shake and shout," then your ABCs. A patient has hypotension, jugular venous distention, and muffled heart sounds on auscultation. The nurse would anticipate that the patient's treatment will be directed at: Reversing cardiogenic shock. Improving left ventricular function. Reducing the degree of ventricular hypertrophy. Managing pericardial effusion or tamponade. The patient's signs are consistent with an increase in venous pressure. Pericardial effusion or cardiac tamponade impairs the ventricles from adequately filling during diastole. Venous pressure increases and stroke volume decreases. Answers 1 and 2 would result in signs and symptoms consistent with left-sided heart failure, and difficulty breathing would likely be present. Hypertrophy (Answer 3) is not reduced, but rather managed through drug therapy. Look for patterns in the options. Three of the choices involve the ventricles—how could you choose just one? On admission of a patient with status epilepticus who has been having a seizure for over 2 hours, the most important assessment data would be: Total time unconscious. Time of last meal. Current arterial blood gases. Time of last dose of anticonvulsant medication. The priority with status epilepticus is the adequacy of the patient's airway and breathing. Measuring the patient's blood gases would be important in determining the need for more aggressive management. Answers 1,2, and 4 are not priority concerns. This is a priority question—if airway is affected, assessing the status will be the best answer. Also note a pattern in the responses: three options have "time," one does not. Choose the one that is different (#3). Which nursing assessment would identify the earliest indication of increasing intracranial pressure? Temperature over 102¦F. Change in level of consciousness. Widening pulse pressure. Unequal pupils. As cerebral hypoxia develops, the patient becomes rest less and drowsy well before any of the characteristic signs and symptoms of increasing intracranial pressure are pre sent. Answers 1,3, and 4 are all consistent with increasing intracranial pressure but occur much later, after there has been significant cerebral herniation and distortion of the brain. The key word in the stem is early. A "change" in level of consciousness (could be restlessness or a lack of responsiveness) is almost always the best answer with neurological problems. A key word in the best option is change. What is the most common reaction to an epidural narcotic for postoperative pain management that a nurse would observe? Slowing of the respiratory rate. Increase in the heart rate. Increased urinary urgency. Itching. Frequently patients complain of severe itching from the opioids used with epidural analgesia. Antihistamines and comfort measures are effective for many patients, as well as reduction in the dosage or administering Narcan to control itching without reversing the analgesic effects. Respiratory depression (Answer 1) is not a common problem with careful titration of standard dosages. Only when the patient becomes sedated does the respiratory function become a concern. Answers 2 and 3 are not expected side effects (however, postural hypo tension and constipation arc potential problems). The clue in the stem is "most common." Look for something annoying but not serious. Otherwise epidural analgesia would not be used as often as it is. Which nursing diagnosis would be a postoperative priority for a patient being transferred from postanesthesia recovery to the surgical floor? Decreased cardiac output related to blood loss. Pain related to large abdominal incision. Risk for infection related to surgical wound. Risk for activity intolerance related to surgery. Maintaining perfusion is the priority in the early postoperative period. Pain Answer 2) would also be important; however, it is not life threatening. Answers 3 and 4 are also important nursing diagnoses, but they are not actual problems, although there is risk potential. This is a priority question. Consider the greatest risk to the patient, meaning the possibility of a life-threatening problem (cardiac). Before administering oxygen therapy, the nurse would: Review patient's history for indications of COPD. Observe patient's respiratory pattern. Draw arterial blood gases. Auscultate bilateral breath sounds. There is a risk to the patient with COPD if the O, flow rate is too high. The patient with COPD has a hypoxic respiratory drive. If the liter flow is above 2 L, there is a risk for respiratory depression. Answers 2, 3, and 4 are important nursing actions to determine the effectiveness of oxygen therapy. Look for patterns in the options. Three options assess the effectiveness of the treatment. One validates the appropriateness of the order. Choose the one that is different, The priority nursing action for a patient admitted with a productive cough, weight loss, and a suspected diagnosis of tuberculosis is: Instruction on preventing disease transmission. Planning for frequent rest periods. Recording accurate intake and output. Reviewing current dietary patterns. Tuberculosis is an airborne infectious disease. Preventing further spread of the disease would be a priority for care. Covering the mouth when coughing, proper disposal of tissues, and hand washing must be reinforced. Answers 2, 3, and 4 are important actions after preventing disease transmission. This is a priority question. Think pre-V vent ion before treatment. A patient who is suspected of experiencing respiratory distress from a left-sided pneumothorax should be positioned: On the left side. On the right side. In semi-Fowler's position. Prone. A pneumothorax exerts a "pushing" pressure on the heart and unaffected lung. Function is compromised. Semi-Fowler's is optimal positioning for chest expansion. Answers 1, 2, and 4 would inhibit chest expansion partially. Visualize each position and how ventilation would be affected. The best position is one that maximizes ventilation and minimizes lung restriction. The most important nursing diagnosis for a patient admitted with an intestinal obstruction is: Risk for aspiration. Risk for fluid volume deficit. Altered nutrition, more than body requirements (hyperkalemia). Nausea. Intestinal obstructions are medical emergencies because of the risk for severe fluid and electrolyte imbalance and the development of hypovolemia. The obstruction prevents normal fluid and electrolyte reabsorption in the small intestine. Although there may be gastric distention and vomiting, which might result in aspiration (Answer 1), it is not a priority or a direct result of the obstruction. Nutrition would be altered (Answer 3), but there would be a deficit of electrolytes (hypokalemia). Nausea (Answer 4) may be present, but it is neither a priority nor stated as a nursing diagnosis. This is a priority question (fluid volume deficit vs. aspiration). Look at the direct result of the obstruction. Following a myocardial infarction and the development of left ventricular failure, a decrease in which of the following laboratory values would be expected? Alanine aminotransferase (ALT). White blood cell count. Creatine kinase isoenzyme. Arterial pH. The post-MI patient with left-sided heart failure, which is also cardiogenic shock, would be experiencing metabolic acidosis. The pH would decrease, consistent with acidosis. Answers 1,2, and 3 would all increase as a result of the myocardial damage. Note the key word: decrease. Know the clinical relevance of laboratory tests. Think what effect myocardial damage would have on each test. The patient becomes pulseless with a monitored rhythm of sinus tachycardia following a motor vehicle accident and a fractured right femur. The nurse should prepare for: Mechanical ventilation and administration of sodium bicarbonate. CPR and epinephrine IV push. Atropine IV and intubation with mechanical ventilation. Isoproterenol (Isuprel) followed by CPR. The patient is most likely in shock. Bicarbonate is needed with metabolic acidosis, which will develop. The compensatory tachycardia will result in poor oxygenation. Although the question does not indicate difficulty breathing, the patient is not being perfused well (pulselessness) and may go into cardiac arrest if emergency treatment is not begun. CPR (Answers 2 and 4) would not be done because there is a heart rhythm, although perfusion is ineffective. Atropine (Answer 3) would not be given because it increases heart rate. Use a process of elimination—CPR is not indicated. Therefore, eliminate #2 and #4. Do you give atropine or sodium bicarbonate for shock? Which of the following symptoms experienced by a patient following an acute MI will most likely be relieved by oxygen administration? Metabolic alkalosis and an elevated CK-MB. Arrhythmias and related hypotension. Sweating and hyperoxemia. Hypertension and AV conduction problems. Oxygen therapy is important to the prevention and treatment of life threatening arrhythmias, which occur often as a result of myocardial ischemia. The ineffective contraction of the heart may result in reduced cardiac output and poor perfusion, leading to hypotension. Acid-base abnormalities and enzymes (Answer 1) do not improve with O,. Hyperoxemia (Answer 3) would not require additional oxygen. Hypertension (Answer 4) is not expected with an Ml; and conduction defects are due to damage to the conduction system and do not respond to O,. Phrase each option as a true-false question and determine if oxygen would improve the patient problem. The blood pressure of a patient, who is scheduled for a femoral-popliteal bypass of the right leg, is 168/120. The most appropriate nursing action would be to: Give the prescribed antihypertensive agent regardless of surgery. Check vital signs frequently to determine further changes in BP. Call the MD to see if surgery can be postponed. Administer an antianxiety agent IV per order. Surgery is usually a stressful situation that increases anxiety. Administration of an anxiolytic such as midazolam (Versed), lorazepam (Ativan), or diazepam (Valium) during the preoperative period may be necessary to lower the blood pressure and prevent any complications. Antihypertensive agents (Answer 1) are usually held before surgery to reduce the risk of hypotension from an adverse interaction with anesthesia. Checking vital signs (Answer 2), although not wrong, would not resolve the patient's preoperative anxiety and stress. An elevated BP possibly related to preoperative stress would not be a reason to cancel surgery (Answer 3). That may only further increase the patient's stress. Do something for the patient's stress first. Only one option deals with the preoperative stress. A patient is scheduled for cardioversion to treat sustained atrial fibrillation. The nursing priority before the procedure would be to: Auscultate the heart sounds. Administer medication for sedation. Give the prescribed analgesic. Start an antibiotic IV per order. During cardioversion the patient is awake but sedated. The anticipation of the procedure may be anxiety producing. Auscultation (Answer 1) would not be necessary, because the patient will be monitored. There should not be any pain (Answer 3) or infection (Answer 4). Look at the time frame. Choose an option that addresses the patient need before the procedure. The nurse determines that the expected normal urine output in 24 hours for a healthy adult is: 720 mL. 840 mL. 1500 mL. 3000 mL. Total normal output for a 24-hour period is 2500 mL, with 1500 mL from urine and 1000 mL from skin, lungs, and feces. Answer 1 is the minimum amount of urine output that is acceptable for a 24-hour period. Answer 2 is accept able, but not normal, and Answer 4 would be excessive; it occurs with diuresis or diabetes insipidus (2-3 L in 24 hours) The key word is normal. Recall that the minimum amount of urine desired for 1 hour is 30 mL, and 3 L is excessive. When numbers (i.e., amounts) are involved, avoid the extremes (too low and too high). The patient's arterial blood gases are as follows: pH 7.43, Po2 83; Pco2 29; HC03 29. The nurse would instruct the patient to: Turn, cough, and deep breathe at least every 2 hours. Get up and walk at least three times a day to improve 02 level. Try to breathe more slowly. Drink more fluids to flush the kidneys. The blood gases are consistent with compensated respiratory alkalosis. The patient is hyperventilating, breathing rapidly and blowing off carbon dioxide. A slower rate, not deeper, will increase the CO, level. Answer 1 will prevent hypoventilation. Answer 2 will prevent complications from immobility (e.g., pneumonia), which would produce an elevated CO,, not O,, level. Fluids (Answer 4) will not improve a blood gas alteration that is the result of a respiratory response. Look at the two options that deal with breathing (deep breaths, breathe slowly). Consider how each option will increase CO, level. Know normal blood gas ranges. A person who is diabetic is brought into the emergency department by a friend who found him on the floor unconscious. The first nursing action would be to: Ask the friend what happened and how long the patient was unconscious. Assess the patient for signs of head trauma when he collapsed. Obtain a blood sugar level and start an IV infusion. 4. Contact the patient's immediate family to come to the hospital. The first action is to measure the glucose level, start an IV, and prepare to give glucose or insulin. A dangerously low blood sugar level is life threatening and must be corrected immediately. Answers 1, 2, and 4 are not incorrect nursing actions; however, they are not the first priority. The key word is, first. Only one option takes a direct action to determine the cause of unconsciousness. A patient with AIDS is afraid of getting toxoplasmosis. The most important precaution to take would be to: Wash all vegetables before cooking. Wear gloves when gardening. Wear a mask when traveling to foreign countries. Avoid contact with cats and birds. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year. Eating raw or undercooked meat, not vegetables (Answer 1), is a mode of transmission. The parasite is transmitted through ingestion, not air (Answer 3). Ingestion of oocysts from cat feces is the most common mode of oral infection in the United States. Cats do not have to be avoided (Answer 4), but handling of litter should be avoided, and hand washing would be essential for a patient who is immunocompromised. When preventing infection, two options are usually desirable choices—-wearing gloves and hand washing. Which information about recommended adult immunizations is accurate to include in health teaching? Tetanus and diphtheria booster is needed at least every 5 years. Pneumococcal pneumonia vaccine may be given once for lifetime protection. Influenza A and B vaccine are given one time, unless high risk. Measles and mumps vaccine are given to college-age students only. Pneumoccocal pneumonia vaccine is given to anyone at high risk for pneumococcal pneumonia or its complications. One immunization is recommended for lifetime protection, although revaccination every 6 years should be considered for high-risk patients. A booster for tetanus and diphtheria (Answer 1) is only needed every 10 years to maintain life long immunity. Answer 3, influenza, is given annually for high-risk individuals. Measles and mumps (Answer 4) is indicated for anyone born after 1956 with an uncertain immune status. Use the process of elimination and what you know about normal pediatric immunization patterns to figure out adult variations. The laboratory findings for a patient with polycythemia vera include major and minor criteria. Which of the following is the major or defining hematological finding? Leukocytosis >12,000/mm3. Thrombocytosis >400,000/mm3. RBC count >6 million/mm3. Elevated leukocyte alkaline phosphatase. Polycythemia vera is a chronic myeloproliferative disorder characterized mainly by erythrocytosis (increased RRC mass). Hemoglobin and hematocrit will be elevated. Answers 1,2, and 4 are also laboratory findings, but they are considered minor criteria in this condition. Know the major physiological abnormality and important diagnostic indicator. Which patient, experiencing a change in cardiac rhythm after a myocardial infarction, would the nurse assess first? A conversion from normal sinus rhythm to atrial fibrillation. An increase in the PR interval to 0.26 seconds. Sinus tachycardia, rate of 110. One unifocal premature ventricular contraction in 1 minute. The development of atrial fibrillation, although not life threatening, will have the greatest impact on hemodynamics; and the patient may experience chest pain, dyspnea, and heart failure following an MI. The patient may automatically revert back to a sinus rhythm; however, the effect of the rhythm change must be assessed. Answers 2, 3 and 4 do not indicate the need for treatment or immediate response on the part of the nurse. Consider which change presents the greatest risk to the patient (e.g., fibrillation). Know the acceptable parameters of cardiac functioning (i.e., what is OK vs. not OK). Preoperative teaching for a patient scheduled for surgery to repair a detached retina will include the following information: Eye patches may be used postoperatively. No eye pain is expected postoperatively. Semi-Fowler's position will be used to reduce pressure in the eye. Return of normal vision is expected following surgery. Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery. A moderate amount of pain is expected (Answer 2). Positioning (Answer 3) depends on the location and severity of the detachment; prone or face down positioning may be required. Vision is usually blurred because accommodation has been paralyzed. A return to normal vision (Answer 4) cannot be predicted pre-operatively. Time sequence (preoperative) points to the best choice. Only one option says "may" be done; the other choices are too definitive ("is expected," "will be used"). When ambulating a patient who is blind, the nurse should be positioned: Behind the patient, holding the patient's elbows. In front, with the patient holding the nurse's arm at elbow. On the patient's side, holding the dominant hand. On the patient's side, holding the nondominant hand. The nurse leading, without holding, the patient is the correct approach. The nurse is the "sight" for the patient, and being ahead of the individual who is blind is more secure and safe for the patient. Answers 1,3, and 4 all have the nurse holding the patient, rather than the patient holding onto the nurse. Look for patterns in the options. Only one has the patient being led by the nurse. The greatest reduction in falls and improved safety for the elderly patient with Parkinson's disease would occur with: Discouraging the patient from wearing slippers. Buying shoes that fit snugly. Raising the height of toilet seats. Patient holding hands behind back when walking. Most falls in the elderly, including those with Parkinson's disease, occur in the bathroom. There is a loss of muscle strength in legs with normal aging. Combined with muscle rigidity and postural instability in Parkinson's, the risk for falls is great. Answers 1 and 2, as stated, are not the most important ways to reduce falls. Nonskid soles and proper fit (not necessarily snug) are safety concerns. Answer 4 improves posture, not necessarily reducing the risk for falling. Visualize each option and how stability would be improved. Assessment of a patient following a recent fracture of the left humerus revealed increasing pain with extension of the fingers of the left hand. Distal pulse is strong in the limb. Capillary refill is brisk, and there does not appear to be any restriction of the fingers from the cast. The most likely explanation of the pain is: Possible development of compartment syndrome. Disuse syndrome from immobility. Normal response to sudden movement of fingers. Compression of nerve at fracture site. Pain from passive movement or stretching of the fingers is characteristic of the development of compartment syndrome. The cast is acting as a "space-limiting" sleeve around the muscle, nerves, and blood vessels, resulting in increased tissue pressure. Skin color, temperature, capillary refill, and quality of peripheral pulses are not reliable clinical indicators of compartment syndrome. The fracture is too recent for disuse (Answer 2). Increasing pain is not normal (Answer 3). Nerve compression (Answer 4) would cause paresthesia or paralysis. Use process of elimination and knowledge of usual signs and symptoms of circulatory, sensory, and motor impairment. A patient who is diabetic states that she is a "peanut butter freak." Which exchange would be equivalent to 2 tbsp peanut butter? 8 oz whole milk. 2 tbsp butter. 1/4 cup cottage cheese. 2 tbsp cream cheese. A diabetic diet is most often based on an exchange system. Foodstuffs in this system are divided into six types. Foods from within each list can be substituted for another in the same list because they have approximately the same food value. Peanut butter is in the meat exchange list, as is cottage cheese, and therefore these can be substituted for one another. Whole milk (Answer 1) is on the milk exchange list. Butter and cream cheese (Answers 2 and 4) are considered to be fats. Think "substitute" for a high-protein source. A patient is placed on an 1800-calorie diabetic diet; a typical lunch would include two meat exchanges, two bread exchanges, one vegetable exchange, one fruit exchange, one fat exchange, and one milk exchange. Given these allowances, which would be inappropriate for this patient to consume at a birthday luncheon? A piece of plain sponge cake. An 8 oz glass of Coca-Cola. A taco (tortilla, meat, cheddar cheese, lettuce). Avocado and orange salad. Given the patient's food allowances, all these foods (Answers 1,3, and 4) would be allowed except for the Coca-Cola. All concentrated sweets and regular soft drinks are contraindication a diabetic diet. Try matching each exchange with the options—one will have no match. The question calls for what is not OK to eat. A patient has been placed on a high-protein diet. Which food would the nurse suggest this patient select? Rice (I cup). Eggnog (8 oz). Cheddar cheese (1 oz). Broccoli (1 cup). Eggs and milk are two sources of protein with the highest biological values (high-quality proteins). Eggnog (8 oz) contains 15 g protein. Rice (Answer 1) contains only 4 g, cheddar cheese (Answer 3) contains only 7 g, and broccoli (Answer 4) contains only 5 g. Meat, fish, and legumes contain more protein than does eggnog, but their percent of protein utilization is lower, making them almost equal in value to eggnog. With two possible choices, choose the one with more sources of protein (egg and milk). Which food would the nurse recommend be avoided by a patient experiencing dumping syndrome? Liver and bacon. Orange and avocado salad. Creamed chicken. Glazed donuts and coffee. Concentrated sugars and carbohydrates should be avoided by these patients. Likewise, fluid ingestion with meals or snacks should also be avoided to prevent rapid emptying of the stomach. Answers 1,2, and 3 are examples of high-protein, high-fat, low-carbohydrate foods, which are appropriate. Know two things to avoid with meals— carbohydrates and fluids. Dietary restriction of protein in chronic renal failure is used to prevent the accumulation of nitrogenous wastes and resulting azotemia. Which food containing amino acids would be allowed in a diet for a patient with chronic renal failure? Roast beef. Milk and eggs. Chicken and turkey. Shellfish. The diet for patients with chronic renal failure is restricted in total amount of protein and amino acid content. Eggs and milk are generally included in the diet because they contain all the essential amino acids. Meats from animals (Answer 1), fowl (Answer 3), and fish (Answer 4) are restricted due to their sulfur-containing, nonessential amino acids. Know that an egg is considered a perfect protein, so it is often a correct choice. Which food may be more likely to cause discomfort in a patient with cholecystitis? Whole milk. Cottage cheese. Whole-grain breads. Eggs. Whole milk has a high fat content, so a patient with cholecystitis is generally advised to switch to low-fat or skim milk. Cottage cheese (Answer 2), whole-grain breads (Answer 3), and eggs (Answer 4) are allowed in a low-fat diet, although eggs may be limited to four per week. Look for the food that is not OK to have. Use a true-false approach option by option to find the item that is high fat and not OK to have. Which food should the nurse advise a patient with a colostomy to avoid? Carbonated drinks. Fresh-cooked green beans. Liver and bacon. Cooked cereals. Carbonated drinks, cabbage, sauerkraut, and nuts tend to increase flatulence, and most patients feel uncomfortable passing flatus into the colostomy bag, because it causes the bag to inflate. Onions, cheese, and fish may cause odorous drainage. Generally the initial diet following a colostomy is a low-fiber diet for several weeks. As the diet is increased, the individual patient can determine more accurately which foods cause constipation, diarrhea, flatus, or dyspepsia. Answers 2,3, and 4 are not troublesome to most such patients. With diet and bowel disorders, look for causes of gas, A patient is a 30-year-old gravida 3 para 2 who is 4 weeks pregnant. She has been a vegetarian for 8 years. She eats no eggs or dairy products (vegan vegetarian). When assessing the adequacy of this patient's diet, to which food group would the nurse pay particular attention? Grains. Protein foods. Vitamin C—rich foods. Fruits and vegetables. Pregnant vegetarians who omit dairy foods may be unable to meet the requirement for an additional 30 g protein per day over their nonpregnant needs. Answer 1 is incorrect because individuals who have been vegetarians for some time usually have evolved diets adequate in grain intake. Answers 3 and 4 are incorrect because individuals who are vegan vegetarians usually ingest a wide variety of fruits and vegetables to meet pregnancy requirements for vitamin C, fiber, and other nutrients. Think about the food group for milk, dairy, and meat—protein. Recall protein requirements during pregnancy and lactation. A patient is a 17-year-old primigravida. At 30 weeks of gestation she is diagnosed with iron deficiency anemia. The patient takes her iron and vitamin supplements sporadically due to unacceptable GI side effects but eats many foods high in iron. In planning diet teaching which nutrient will the nurse emphasize to promote heme production? Niacin. Vitamin A. Vitamin D. Folic acid. Folic acid (folacin) is essential for increased heme production for hemoglobin and prevention of megaloblastic anemia. Answer 1 is incorrect because niacin has no direct or indirect role in erythropoiesis or heme production. Answer 2 is incorrect because vitamin A is essential for fetal hone growth and tooth development. Answer 3 is incorrect because vitamin D is essential for mineralization of bone tissue and calcium and phosphorus absorption. Know the nutritional benefit of common vitamins and minerals. A patient has meperidine, 75 mg every 34 hours prn, ordered for postoperative pain. Before administering this narcotic, the nurse should: Position in a semi-Fowler's position to minimize respiratory effects. Assess the type, location, and intensity of discomfort. Evaluate whether the pain is real. Try other measures to relieve discomfort, such as position change. Before administering any narcotic, the nurse should assess the type, location, and intensity of pain, as well as factors that seem to precipitate or relieve it. Meperidine, like morphine, has hypotensive and respiratory depressant effects. Positioning in anticipation of respiratory changes is not indicated (Answer 1). Pain and discomfort are subjective symptoms that are always real to the patient (Answer 3). Based on the information gained in Answer 2, it is then possible to decide whether the patient needs supportive measures (such as back rub or position change as in Answer 4), the bedpan, and/or the administration of a narcotic. Choose the first step in the nursing processassess. Neostigmine bromide (Prostigmin), 0.5 mg subcutaneously stat, is ordered by a patient's physician to relieve urinary retention. The nurse knows that this drug is classified as: A cholinergic. An anticholinesterase. An anticholinergic. A beta blocker. Neostigmine bromide (Prostigmin) is an anticholinesterase. It enhances bladder tone and contraction, enabling complete emptying of the bladder. It is also used in the treatment of myasthenia gravis. Bethanecol chloride (Urecholine) is an example of a cholinergic drug (Answer 1), also used to treat postoperative urinary retention. Atropine is an example of an anticholinergic drug (Answer 3), which would act to inhibit initiation of urination. Beta blockers (Answer 4) such as propranolol do not affect the bladder. Know expected effects of common drug classifications. The nurse explains to a patient that although salicylates are given to relieve pain in rheumatoid arthritis, they also function as an: Analgesic. Anti-inflammatory. Anticholinergic. Antiadrenergic. Salicylates, particularly acetylsalicylic acid (aspirin), are given in divided doses after each meal and at bedtime for their analgesic (reduced pain), anti-inflammatory (reduced swelling), and antipyretic (reduced fever) effects. Answer 1 is incorrect because relief of pain was already described in the question. Answers 3 and 4 are incorrect because salicylates neither inhibit nor stimulate the autonomic nervous system synapses. Consider why the drug relieves pain decreased inflammation. Drug therapy goals for a patient include strengthening cardiac contraction and increasing glomerular filtration rate. Which medication would the nurse prepare to accomplish both goals? Epinephrine. Digoxin. Furosemide (Lasix). Hydralazine. Digoxin increases the force and velocity of cardiac contraction and slows the heart rate by delaying conduction through the atrioventricular node. The hemodynamic effects of its action include increased cardiac output, decreased right atrial and venous pressures, decreased left ventricular filling pressure, and increased excretion of sodium and water. Epinephrine (Answer 1) increases the force of cardiac contractions but also increases heart rate, which in this case would increase cardiac embarrassment. Furosemide (Lasix) (Answer 3) is a rapidly acting diuretic that enhances excretion of sodium and water. However, although its use is indicated to reduce fluid volume during the acute phase of pulmonary edema, it has no known direct effects on the cardiac musculature. Hydralazine (Answer 4) is a peripheral vasodilator used in hypertensive therapy. It is not indicated in this situation. Know the expected therapeutic effects. Would increased or decreased heart rate improve cardiac output and renal blood flow? Which outcome is the best indicator that digoxin has been effective? Increased systolic and diastolic pressures. Unlabored respirations and increased urinary output. Decreased pulse rate and increased urinary output. Increased blood pressure and decreased pulse rate. The best indicator that digoxin has been effective in strengthening cardiac contraction and increasing glomerular filtration is a decrease in heart rate (vagal effect) and increased urinary output. As a result of these drug effects, cardiac output is improved, raising blood pressure and decreasing pulmonary congestion. Answers 1,2, and 4 are only partially correct. Look for one expected effect (increased urinary output) to help eliminate two other options. Patient teaching includes the early side effects of theophylline administration, which are: Tachycardia and palpitations. Anorexia, nausea, and vomiting. Restlessness and tremors. Headache and insomnia. Theophylline relaxes bronchial smooth muscles, which helps relieve the wheezing and coughing associated with bronchospasm. Side effects are rare, but the earliest signs of overdose are usually anorexia, nausea, and vomiting. Tachycardia (Answer 1), restlessness and tremors (Answer 3), headache and insomnia (Answer 4), are side effects associated with bronchodilators. Know expected outcomes of drug therapydesired and untoward effects. Based on the peak action of furosemide (Lasix) PO, the nurse will evaluate the drug's effects in: 30-60 minutes. 1-2 hours. 3-4 hours. 6-8 hours. Furosemide is a rapidly acting diuretic with a peak action in 1-2 hours and a duration of 6-8 hours. The peak time is too rapid for Answer 1 and too long for Answers 3 and 4. Notice the time overlapthe option that includes both is better. The nurse administers sodium polystyrene sulfonate (Kayexalate) knowing that the drug reduces hyperkalemia by: Exchanging sodium ions for potassium ions in the GI tract, thereby increasing potassium excretion in the feces. Inhibiting potassium absorption sites in the GI tract. Promoting diarrhea, thereby decreasing potassium absorption from the gut. Altering the effects of aldosterone in the kidney tubules. Sodium polystyrene sulfonate (Kayexalate) is a cation-exchange resin. As it passes along the intestine or is retained in the colon after enema administration, sodium ions are partially released and replaced by potassium ions, allowing for fecal excretion of potassium ions. This drug is extremely unpalatable and may be administered in syrup, chilled, or mixed in the diet, and if necessary, administered directly into the stomach per nasogastric tube. Side effects of administration include anorexia, nausea, vomiting, constipation,hypokalemia, hypocalcemia, and sodium retention. Answers 2,3, and 4 are not actions of sodium polystyrene sulfonate. Know the common therapies for increased K plus ion exchange; also glucose and insulin, sorbitol. Focus on the options that include increasing Kplus excretion rather than decreasing Kplus absorption (Answers 2 and 3). The nurse knows that the best time to give oral iron preparations is: With meals, to decrease gastric upset. 1 hour before eating, to enhance absorption. 1 hour after eating, to slow absorption. At bedtime. Ideally, oral iron preparations should be taken on an empty stomach (2). However, they tend to irritate the gastric mucosa, so they should be administered with or immediately after meals to ensure patient compliance. Thus Answers 2,3, and 4 are not the best Answers. Patients may complain of constipation or loose stools. Stools will change color (dark green to black). Ferrous sulfate is apt to deposit on teeth and gums, so frequent oral hygiene is necessary, and therapy will need to continue even after hemoglobin levels return to normal, to ensure adequate iron stores in the body. Key word is best time.Answer 1 is better than Answer 3. Iron is harsh on the stomach. A patient is instructed to report the following side effect of neomycin administration: Deafness. Nausea. Diarrhea. Anaphylaxis. Toxic doses of neomycin may result in eighth cranial nerve damage much like that produced by streptomycin. Kidney damage may also occur, extending from milk albuminuria to elevation in blood urea nitrogen. Nausea (Answer 2) is common with ingestion of antibiotics, though not specific to neomycin. Erythromycin most commonly causes nausea, vomiting, and diarrhea (Answer 3). Anaphylactic reactions (Answer 4) are associated most commonly with penicillin administration. Use a process of eliminationfind a specific, serious side effect that can occur. Drug would not be given in the first place with known allergic potential (because of anaphylaxis); GI upset is common to most antibiotics, and not specific to neomycin. Before administering morphine sulfate, the nurse should check: Apical and radial pulse. Respiratory rate. Urinary output. Skin color and turgor. Morphine strongly depresses the medullary respiratory centers. Therefore, before administering the narcotic, the nurse should assess the patient's respiratory rate and depth to prevent severe respiratory depression. Answers 1,3, and 4 are not affected by morphine. Know which systems (in this case, respiratory) respond to commonly used drugsparticularly pain medications. The nurse administers spironolactone (Aldactone) knowing that it is classified as: An aldosterone antagonist. A carbonic anhydrase inhibitor. A thiazide. An osmotic diuretic. Spironolactone (Aldactone) is an aldosterone inhibitor, inhibiting the effects of hyperaldosteronemia, which is common in cirrhosis. This drug safely increases sodium and water excretion but does not cause concomitant losses of potassium as do other diuretics. For this reason, potassium supplements are not generally given to the patient. An example of a carbonic anhydrase inhibitor (Answer 2) is acetazolamide (Diamox); an example of a thiazide (Answer 3) is chlorothiazide (Diuril) or hydrochlorothiazide (HydroDIURIL); and an example of an osmotic diuretic (Answer 4) is mannitol. Look for clues from the stem, such as V similarity in wordsaldactone and aldosterone. Which supplement would the nurse not ordinarily administer to the patient receiving spironolactone? Vitamin B. Potassium chloride. Ascorbic acid. Calcium carbonate. Potassium chloride is not given since the patient is on spironolactone (Aldactone), which does not cause concomitant losses of potassium as do other diuretics. For this reason, potassium supplements are nor generally given to the patient. Spironolactone would not contraindicate the administration of vitamin B6 (Answer 1), ascorbic acid (Answer 3), or calcium gluconate (Answer 4). Know the expected outcome of potassium-sparing diuretics. Know drug classifications. The primary objective in giving prednisone along with aspirin for acute rheumatoid arthritis is: To inhibit the autoimmune factors associated with rheumatoid arthritis. To prevent further joint destruction. To decrease inflammation and suppress symptomatology. To increase glucose levels for tissue repair. The primary objective in giving corticosteroids is to lessen the symptoms of the disease process. Most patients initially respond well to these drugs; however, as the disease progresses, higher and higher doses are required to relieve symptoms. Answers 1 and 2 are incorrect because corticosteroids have no curative effects, only palliative. Many of the side effects of corticosteroid administration are due to the effects of these drugs on glucose metabolism (Answer 4), such as Cushing-like syndrome. Look for an option that will improve an "itis"inflammation. The nurse would recognize prednisone toxicity if which of the following occurred? Tinnitus. Exfoliative dermatitis. Glucosuria. Nausea and vomiting. Side effects of prednisone therapy mimic the manifestations of Cushing's syndrome (moon facies, abnormal fat deposits, purple striae, hyperglycemia with glucosuria, hypertension, obesity, and emotional disturbances). Side effects of other drugs used in the management of rheumatoid arthritis include tinnitus (Answer 1), from aspirin; nausea, vomiting (Answer 4), headaches, and vertigo with indomethacin (Indocin) administration; and dermatitis ranging from erythema to exfoliative dermatitis (Answer 2) with gold salts therapy. Know the untoward effects of excessive steroids on the body. Propantheline bromide (Pro-Banthine) is given to patients with cholelithiasis and cholecystitis because it: Reduces gastric secretions and intestinal hypermobility. Decreases bile secretion by the liver and gallbladder. Slows the emptying of the stomach, thereby reducing chyme in the duodenum. Inhibits contraction of the gallbladder and the bile duct. Although the primary use of propantheline bromide in many clinical situations involving the gastrointestinal tract is to reduce gastric secretions and intestinal hypermotility, it is used in gallbladder disease because of its antispasmodic effects an the gallbladder and bile duct. Answer 1 is therefore correct, but not the best choice. Answers 2 and 3 are incorrect because propantheline bromide does not reduce bile secretions; its calming effect on gastric motility does not reduce the amount of chyme entering the duodenum. Look for an option that alleviates and explains a possible cause of gallbladder pain. The nurse would most likely give papaverine HCl for relief of gallbladder pain rather than morphine SO,, because: Morphine depresses gallbladder contractions, thereby decreasing bile secretions. Opiates tend to mask symptoms in patients with acute abdomen. Morphine tends to increase contractions of the sphincter of Oddi, thereby increasing intraductal pressures. Morphine relaxes smooth muscles, thereby increasing bile production. Morphine sulfate causes spasms of the sphincter of Oddi, thereby increasing intraductal pressures and abdominal pain. Papaverine and meperidine, both synthetic opiates, as well as nitroglycerin, may be administered to relieve pain associated with gallbladder disease. Answer 1 is incorrect because the effect of morphine is to increase spasms in the gallbladder. Answer 2, though correct, is not the best Answer Opiates are withheld when a patient has an acute abdomen and the diagnosis is unknown or tentative. In this case, the patient has an established history of gallbladder disease and specific symptomatology. Answer 4 is incorrect, in that although morphine does relax vascular smooth muscle, this effect does not increase bile synthesis in the liver. Look for options that are opposites increase or decrease contractions. Which would likely cause pain? The nurse can anticipate side effects of hydrochlorothiazide because it is classified as: An aldosterone inhibitor. A carbonic anhydrase inhibitor A potassium-sparing drug. A potassium-wasting drug. Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of water, sodium, and chloride by inhibiting the reabsorption of sodium ions in the distal ascending limb of the loop of Henle and in the distal convoluted tubule of the nephron. Natriuresis promotes the secondary loss of potassium, so this drug is classified as potassium wasting. Spironolactone is an example of an aldosterone inhibitor and is a potassium-sparing diuretic (Answers 1,3). Acetazolemide (Diamox) is the most frequently employed carbonic anhydrase inhibitor (Answer 2). Know the common side effects of frequently used diuretics. Potassium is usually lost (wasted). Focus on two contradictory options. You know potassium is involved; decide whether it is spared or wasted. The nurse knows that hydrochlorothiazide exerts its primary effect on: The proximal and distal tubules of the kidney. The distal convoluted tubule of the kidney only. The distal ascending loop of Henle and the distal tubule of the kidney. The descending loop of Henle and the proximal tubule of the kidney. Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of water, sodium, and chloride by inhibiting the reabsorption of sodium ions in the distal ascending limb of the loop of Henle and in the distal convoluted tubule of the nephron. Natriuresis promotes the secondary loss of potassium, so this drug is classified as potassium wasting. Answer 1 describes the effect of the carbonic anhydrase inhibitors, e.g., acetazolemide (Diamox). Answer 2 would be the effect of the potassium-sparing diuretics such as spironolactone (Aldactone). Answer 4 is the site for the osmotic diuretics, e.g., mannitol, urea. Picture a functional nephron unit from a physiology bookknow the action point for the most common diuretics. Assessment for the side effects of hydrochlorothiazide includes signs of: Hypernatremia. Hyperkalemia. Hypochloremia. Hypouricemia. Thiazide diuretics promote the excretion of sodium, chloride, bicarbonate, and potassium. However, chloride excretion tends to be proportionately greater than bicarbonate excretion, so therapy may result in hypochloremic alkalosis. Hyponatremia, not hypernatremia (Answer 1), occurs. Hypokalemia, not hyperkalemia (Answer 2), may develop, especially with brisk diuresis. Supplemental KC1 therapy and/or increased dietary intake of potassium is indicated with thiazide therapy. Answer 4 is incorrect because it says hypouricemia and hyperuricemia result, which may precipitate frank gout. When potassium loss (hypokalemia) is not a choice, think what else goes with Kplus to balance the shift (CI). A 2-year-old child (diagnosis: meningitis) is to be sedated with phenobarbital, 18 mg PO q6h. The label reads "20 mg per 5 mL." How much phenobarbital should the nurse administer to this child? 4mL. 4.3 mL. 4.5 mL. 4.8 mL. The formula for finding the correct Answer is Dose desired/Dose on hand = it/Amount on hand. 18/20 = x/5 20x= 18(5) x = 18(5)/20 x = 4.5 mL The age of the patient is a distractor. Know the formula; the dose on hand is 5 mL. A patient's CSF culture is positive for Haemophilus influenzae meningitis. To protect other members of the patient's family who have been exposed to meningitis, the nurse should explain that they may be given: Amoxicillin/clavulanate potassium (Augmentin). Sulfisoxazole. Rifampin. Immune serum globulin. Rifampin is the drug of choice for the prophylactic treatment of Haemophilus influenzae meningitis. The usual dose is 20 mg/kg/day in a single dose for 4 days. Amoxicillin/clavulanate potassium (Augmentin) (Answer 1) sulfisoxazole (Answer 2) and immune serum globulin (Answer 4) are not the drugs of choice to prevent H. influenzae meningitis. Use the process of eliminationthe stem says prevent; two options are treatment for infections, and one option has minimal effect in many situations (immune globulin). Select a broad-spectrum antibiotic for prophylaxis. The nurse is to administer pancreatin to a child with cystic fibrosis. To evaluate the effect of this medication, the nurse should know that the primary purpose of this medication is to increase the absorption of: Glucose. Vitamin C. Sodium chloride. Fats. Pancreatin (Viokase) is an exocrine pancreatic supplement used as a digestive aid in cystic fibrosis; its primary use is to promote the absorption of fats. Pancreatin has no effect on the absorption of glucose (Answer 1), vitamin C (Answer 2), or sodium chloride (Answer 3). Know the digestive problem (fat) with cystic fibrosis. The nurse about to administer medication to a 5-year-old patient notes that the child has no ID bracelet. The best way for the nurse to identify this patient would be to ask: The child, "Is your name?" The adult visiting, "The child's name is?" The other children in the room what the child's name is. Another staff nurse to identify this child. The only acceptable way to identify a 5-year-old patient is to have a parent or another staff member identify the patient. Answer 1 is incorrect because most 5-year-old children, under the age of reason, cannot legally be held accountable for self-identification. Answer 2 is incorrect unless the nurse is sure this adult is this patient's patent. Also, it would be better to ask, "What is the child's name?" Answer 3 is also incorrect; children cannot legally be held accountable for identifying other children. Look for the person with the legal responsibilityparent or, if not present, staff. In teaching a parent how to administer Cortisporin eye drops to an infant, the nurse would be most correct in advising the parent to place the drops: Directly onto the infant's sclera. In the inner canthus of the infant's eye In the outer canthus of the infant's eye. In the middle of the lower conjunctival sac of the infant's eye. The recommended procedure for administering eyedrops to any patient calls for the drops to be placed in the middle of the lower conjunctival sac. Placing drops directly onto the sclera (Answer 1) is irritating and less effective. Placing drops in the inner canthus of the eye (Answer 2) may lead to systemic. effects from absorption via tear ducts. Placing drops in the outer canthus of the eye (Answer 3) results in loss of medication and may also cause infection. The age or size of the patient is a distractor; correct technique for eyedrops does not change. The doctor orders ferrous sulfate (Fer-in-Sol), 0.6 mL PO tid. For maximum absorption, the nurse should plan to administer this medication: Between meals. Before meals. During meals. After meals. Maximum absorption of Fer-in-Sol occurs between meals, when hydrochloric acid is freely available in the stomach. When given before meals (Answer 2), it may cause GI upset, which will interfere with eating. When given during meals (Answer 3) or after meals (Answer 4), there is slowed absorption of the drug; however, GI upset is minimized. The stem says maximum: when is HC1 readily available? The question does not ask about avoiding GI upset. Two weeks after starting an oral iron supplement, the patient's mother tells the nurse that the child's stools are black. The nurse should advise the mother: This is a normal side effect and means the medication is working. I will notify the doctor, who will probably decrease the dosage slightly. I will need a specimen to check the stool for possible bleeding. You sound quite concerned. Would you like to talk about this further? When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well. Answers 2, 3, and 4 would only increase the parents' anxiety and lead them to believe that the stool color was abnormal. Know the expected outcome of drug therapies, particularly changes in urine or feces color. Iron and black stools = a good thing! A pregnant woman's history reveals 12 weeks of gestation, severe pruritus, dysuria, and thick creamy vaginal discharge for the past 3 days. Which assessment factor is considered predisposing to the development of monilial vaginitis? Pregnancy. Late adolescence. High-carbohydrate diet. Sickle cell anemia. Normal pregnancy alters vaginal pH and favors the growth of yeast organisms (Candida). Answer 2 is wrong because age is not a factor in the development of yeast vaginitis. Answer 3 is wrong because ingestion of large amounts of carbohydrates does not alter vaginal pH. Answer 4 is wrong because sickle cell anemia is not a predisposing factor in yeast vaginitis. Use a process of elimination. Use what you do know about risk factors of monilia in pregnant women {not age or sickle cell anemia). What alters the pH of the vagina? Health teaching for a patient with vaginal infection with Candida albicans should be planned and implemented to ensure her consistent and appropriate use of the prescribed medication. Which medication is effective in the treatment of monilial (yeast) vaginitis? Metronidazole (Flagyl) oral tablets. Nystatin (Mycostatin) vaginal suppositories. Local applications of podophyllin. Antibiotic (bacitracin) ointment. Nystatin is the drug of choice for treatment of vaginal infections caused by Candida albicans. Answer 1 is wrong because metronidazole is used in treatment of trichomonal vaginitis. Answer 3 is wrong because podophyllin is used in treating venereal warts. Answer 4 is wrong because bacitracin ointment is used in treating skin infections. Method of administration is a clue (i.e., v~ "vaginal" in the stem and "vaginal" in the option) Reviewing the results of a patient's routine prenatal lab work, the nurse notes that her VDRL is positive. To protect the fetus from congenital syphilis, the patient must receive treatment before weeks 18-20. History suggests possible allergy to penicillin. Which drug would be ordered to treat venereal disease in the penicillin-allergic patient? Streptomycin. Sulfisoxazole (Gantrisin). Chloramphenicol (Chloromycetin). Erythromycin. Erythromycin or tetracycline is commonly used in treating penicillin-allergic patients with venereal disease. Answer 1 is wrong because streptomycin is used in treating tuberculosis.Answer 2 is wrong because sulfisoxazole is most commonly used to treat urinary tract infections. Further, its use is contraindicated in pregnancy. Answer 3 is wrong because chloramphenicol is used in treating Salmonella infections and is also contraindicated during pregnancy. Match drugs listed with primary conditions for which each are used. Eliminate two of the drugs that are contraindicated during pregnancy. Recognize erythromycin as the choice when penicillin is indicated but allergy exists. Health teaching regarding uncomfortable signs and symp toms of side effects of oral antibiotic therapy includes: Tinnitus (ringing in the ears). Nausea, vomiting, and abdominal pain. Nausea and glossitis. Nausea, diarrhea, and vaginal yeast infections. Prolonged, heavy doses of oral antibiotics are irritating to the GI tract and result in nausea and diarrhea; yeast infections are common sequelae of antibiotic therapy. Answer 1 is wrong; tinnitus is a symptom of streptomycin toxicity. Answer 2 is wrong because abdominal pain is more commonly associated with sulfisoxazole therapy. Answer 3 is wrong because glossitis and stomatitis are associated with chloramphenicol therapy. Recognize commonly occurring side effects of antibiotics. Prepare patient to manage. Which medication is ordered most commonly to attempt to inhibit premature labor? Diazepam (Valium). Betamethasone. Ritodrine (Yutopar). Bromocryptine mesylate (Parlodel). Ritodrine is the drug of choice when attempting to inhibit labor. Answer 1 is wrong because diazepam is used most commonly as an anticonvulsant. Answer 2 is wrong because betamethasone is used to stimulate production of fetal pulmonary surfactant. Answer 4 is wrong because bromocryptine mesylate is used to inhibit lactation in non-breastfeeding mothers. Know the main use for each of the four drugs listed in order to eliminate the three that are wrong. In evaluating a patient's response to beta-mimetic therapy used to inhibit premature labor, to which sign of side effects must the nurse be alert? Maternal hypertension. Fetal bradycardia. Maternal and fetal tachycardia. Uterine hypertonia. Persistent maternal tachycardia (over 140 beats/min) is a sign of impending pulmonary edema in patients receiving beta-mimetic drugs; fetal tachycardia is a common result of ritodrine therapy. Answer 1 is wrong because ritodrine commonly results in maternal hypotension. Answer 2 is wrong because the common fetal reaction to beta-mimetics is tachycardia. Answer 4 is wrong because ritodrine is given to reduce uterine hyperirritability and threatened premature labor. Look for clues. Mimetic looks like mimicwhich option mimics beta effects? Choose the option That includes mother and fetus. Know effects of drug classes generally. When a parturient is given a paracervical block, the nurse can expect: Low forceps birth. Depression of contractions, maternal hypotension, fetal bradycardia, postnatal uterine atony. Depression of contractions and fetal bradycardia. Loss of bearing-down reflex, low forceps birth. Depression of contractions and fetal bradycardia are expected effects of paracervical block. Answer 1 is incorrect because the bearing-down reflex is not affected by this anesthesia and therefore low forceps birth is usually not needed. Answer 2 is incorrect because maternal blood pressure and postnatal uterine contractility are not affected by paracervical block. Answer 4 is incorrect because the bearing-down reflex is not affected, and therefore forceps birth is usually not needed. Recognize expected effects. Eliminate choices 1 and 4 that would increase risk to the infant (forceps). Review why fetal bradycardia occurs. When a parturient is given epidural (or caudal) anesthesia, the nurse could expect: Maternal hypotension, low forceps birth, needs to remain flat in bed for several hours after birth. Loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth. Loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth, postnatal bladder atony, postnatal uterine atony. Depression of contractions, maternal hypotension. The medication never mixes with cerebrospinal fluid, and therefore there is no need for the woman to lie flat for several hours after receiving this form of anesthesia (Answer 1). Answers 2 and 4 are incorrect because the lists are incomplete. Choose the most complete list in this question, where Answer 3 incorporates 2 and 4. When a parturient is given saddle block (low spinal) anesthesia, the nurse can expect: Loss of bearing-down reflex, maternal hypotension, low forceps birth, need to remain flat in bed for several hours after birth. Fetal bradycardia, low forceps birth, postnatal uterine atony, need to remain flat in bed for several hours after birth. Loss of bearing-down reflex, low forceps birth, postnatal bladder atony, postnatal uterine atony. Loss of bearing-down reflex, maternal hypotension, low forceps birth, need to remain flat in bed for several hours after birth, fetal bradycardia, postnatal uterine atony, postnatal bladder atony. All of the listed effects are to be expected following spinal anesthesia: loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth, postnatal bladder atony, need to remain flat in bed for several hours after birth, and postnatal uterine atony. Answers 1,2, and 3 are incorrect because the lists are incomplete. Choose the option that includes all the others. A patient is receiving tetracycline preoperatively in preparation for bowel surgery. Which common side effect should the nurse instruct the patient to expect with tetracycline? Urticaria. Urinary retention. Jaundice. Deafness. Hypersensitivity reactions (urticaria and hives) are common drug reactions. Photosensitization (exaggerated sunburn) in certain hypersensitive persons may also occur with exposure to direct or artificial sunlight during tetracycline use. Urinary retention (Answer 2) is a side effect of anticholinergic and antihistamine drugs, Jaundice (Answer 3) from drug toxicity is more common with isoniazid (1NH), acetaminophen, phenothiazines (chlorpromazine [Thorazine]), sulfonamides, and antidiabetic drugs (e.g., tolbutamide [Orinase]). Hepatotoxicity may occur with tetracycline, but it is less common. Answer 4, deafness (ototoxicity), is a major side effect of the aminoglycoside antibiotics (e.g., gentamicin, neomycin, streptomycin, tobramycin) and diuretics, such as furosemide and ethacrynic acid. This is an expected common side effect. Only one would be clinically acceptable, although annoying (rash). The following activities have been planned for a patient who is mute and autistic. In which activity will it be important for the nursing staff to take precautionary measures for a common side effect of Thorazine (chlorpromazine), which has been prescribed for this patient? Shopping in an enclosed mall after lunch. Attending the symphony on Wednesday evening. A day at the beach, if the weather permits. A morning at the art museum. The patient needs to be protected against photosensitivity and dermatitis when exposed to the sun; a sunscreen preparation should be applied to exposed parts of the skin, and the patient should wear long sleeves and cover-up clothing. Answers 1, 2, and 4 refer to indoor activities, where there is no danger of sunburn. Which Answer is not like the others? Look at patterns: three indoor activities and one outdoor. Select the one that is different. Some patients who are on phenothiazines are also given benztropine mesylate (Cogentin). The nurse administers this medication in order to: Prevent skin reactions. Increase the effectiveness of the phenothiazines. Decrease motor restlessness. Reduce extrapyramidal side effects. This is the best choice because it encompasses Answer 3. Answers 1 and 2 are definitely incorrect. When two options are correct, choose the one that covers them both. A patient has been on IM fluphenazine (Prolixin) for 3 years. This patient has recently complained of frequent sore throats and malaise. What potentially serious side effect might these symptoms indicate to the nurse? Agranulocytosis. Akathisia. Dystonia. Dyskinesia. Blood dyscrasias often are overlooked when first symptoms of possible adverse drug effects appear in the form of a minor cold. Answers 2, 3, and 4 refer to extrapyramidal tract symptoms that are not life threatening. Which Answer is not like the others? One option is potentially life threatening (hematological system); three are not life threatening and relate to the musculoskeletal system. When nialamide (Niamid) or isocarboxazid (Marplan) is administered, what must the nurse know about the effects of these drugs? They lower the threshold for seizures. They potentiate the effects of many other drugs and common foods. They decrease muscular contractions. They commonly cause obstructive jaundice. Hypertensive crisis can be precipitated by combining this drug with common cold medications and foods high in tyramine or pressor amines (e.g., yogurt, Chianti wine, cheese, Coca-Cola, coffee). All other options are incorrect. Application of knowledge about side effects of these two drugs and the drug classification (monoamine oxidase inhibitor) will lead you to the only correct Answer. Lithium salts are frequently used to treat manic disorders. What side effect is the nurse least likely to observe? Slurred speech. Twitching and athetotic movements. Motor weakness. Tardive dyskinesia. This effect is seen in patients taking a major tranquilizer. All of the other options are likely side effects of lithium salts. Note the word "least" likely. Recall that Answer 4 is a symptom of a different drug category than lithium (Phenothiazine). A 9-month-old patient has been diagnosed with Hirschsprung s disease. At this time, the child is admitted to the hospital for a temporary colostomy; preoperatively, the doctor orders kanamycin. The nurse caring for this child should know that kanamycin is being given to: Increase peristalsis. Decrease amount of GI secretions. Promote passage of stool and flatus. Decrease number of intestinal flora. Kanamycin is an antibiotic that, although poorly absorbed in the GI tract, is often used as part of bowel prep before abdominal surgery. It acts as a bacteriocidal agent, thus significantly decreasing the number of intestinal flora and reducing risk of peritonitis in the postop period. Kanamycin does not increase peristalsis (Answer 1), promote passage of stool or flatus (Answer 3), or decrease amount of GI secretions (Answer 2). The age and diagnosis do not matter. Why would any patient need an antibiotic preoperatively? "Mycins" such as Kanamycin, erythromycin, streptomycin are antibiotics that decrease bacterial growth. A 22-month-old patient is admitted to the pediatric unit for observation following accidental ingestion of 17 children's acetaminophen (Tylenol) caplets. In the first 2-3 days following this child's admission, it is essential that the nurse plan to observe the child closely for signs of: Hepatic failure. Renal failure. Hyperthermia. Hemorrhage. The major toxic effect of an overdose of acetaminophen (Tylenol) is liver failure; liver function should be closely monitored during the first 23 days following the ingestion of acetaminophen. Renal failure (Answer 2) may occur as a late complication of acetaminophen toxicity, as may bleeding and hemorrhage (Answer 4). Hyperthermia (Answer 3) is not a major symptom of this type of ingestion; it is more common in salicylate ingestion. Know the functions of the liver, including detoxification of substances such as medications. In an acetaminophen (Tylenol) overdose situation, the nurse should have on hand the antidote to acetaminophen, which is: Acetylcysteine (Mucomyst). Potassium chloride. Aspirin. Heparin. Acetylcysteine (Mucomyst) is the antidote for acetaminophen poisoning: it serves to protect the liver, ft is usually given orally in a carbonated beverage (e.g., cola), but it can also be given via nasogastric tube. A loading dose is followed by q4h doses until a total of 18 doses have been given. KC1 (Answer 2), aspirin (Answer 3), and heparin (Answer 4) are not antidotes for acetaminophen and do not serve to protect the child's liver. Use a process of elimination. The potential adverse effects of three of the options would likely preclude use as an antidote. The doctor orders aminophylline, 100 mg via IV, for a child who is having an acute asthmatic attack. The nurse should know that the main reason the doctor ordered aminophylline is because it is a(n): Bronchodilator. Anticholinergic. Expectorant. Mucolytic agent. Aminophylline, a bronchodilator that acts as a smooth-muscle relaxant, is used to prevent and relieve symptoms of bronchial asthma. Anticholinergics (Answer 2) are used to treat muscle spasms along the GI tract. Aminophylline is neither an expectorant (Answer 3), which would assist in the removal of mucus from the respiratory tract, nor a mucolytic agent (Answer 4), which would help thin out viscid secretions. Know the drug classifications of frequently used medications. Remember that in asthma, bronchioles constrict; therefore, a bronchodilator is used. While aminophylline is infusing, the nurse should plan to closely monitor the patient's: Level of consciousness. Blood pressure. Cardiac rhythm. Temperature. A transient side effect of IV aminophylline is an increase in heart rate; toxic effects include a prolonged increase in heart rate and abnormalities in cardiac rhythm. While receiving IV aminophylline, the patient should be on a cardiac monitor, and both rate and rhythm should be closely monitored and documented by the nurse. Aminophylline may also cause a transient change in the blood pressure (Answer 2), but this is not as much a concern as the patient's cardiac rhythm. Aminophylline should not affect level of consciousness (Answer 1) or temperature (Answer 4); thus there is no particular need for the nurse to monitor these specifically at this time. With two potentially correct Answers, select the more encompassing choicechange in heart function will ultimately affect BP. The words "closely monitor" in the stem usually rail for a priority Answer (cardiac is usually a priority). The nurse should know that, to prevent future asthmatic attacks, a patient will most likely receive: Theophylline. Cromolyn sodium. Prednisone. Diphenhydramine. Cromolyn sodium, an uncategorized drug used as an adjunct in the treatment of asthma, is used only after the acute attack is relieved; its primary intent is prophylaxis, i.e., to prevent future attacks. Cromolyn is used in an inhaler. It is absorbed into the systemic circulation after its inhalation into the lungs. It acts on the mast cells and also inhibits the release of histamine. Theophylline (Answer 1), prednisone (Answer 3), and diphenhydramine (Answer 4) do not prevent future asthmatic attacks and have no prophylactic value. Look for a pattern: three of the options are used for acute episodes; choose the one that meets the condition of the stem (future prevention). A 15-year-old patient is admitted to the hospital with a diagnosis of infectious hepatitis (type A). To protect other members of this patient's family who have been exposed to infectious hepatitis, the nurse should explain that they may be given: Amoxicillin/clavulanate potassium (Augmentin). Sulfisoxazole. Rifampin. Immune globulin. Immune serum globulin (ISG) offers the family members some protection against type A infectious hepatitis. It contains antibodies against the organism and will aid the family members in resisting this infectious disease. Amoxicillin/ clavulanate potassium (Augmentin) (Answer 1) and sulfisoxazole (Answer 2) are antibiotics used for a variety of infections, but they would not prevent hepatitis. Rifampin (Answer 3) is used prophylactically for Haemophilus influenzae meningitis and to treat TB but would not prevent hepatitis. Know when immune globulin may be effective (infectious hepatitis) and when it is not (H. influenzae meningitis). Remember that protection for hepatitis exposure is achieved through passive immunity (i.e., immune serum globulin). A 17-month-old child has retropharyngeal abscess and is to receive ampicillin four times a day. The child weighs 15 kg (33 lb). The nurses' reference indicates that the correct dosage is 75 mg/kg/day. Which dose should the nurse give to this patient at 10 A.M.? 11 mg. 28 mg. 280 mg. 1125 mg. The nurse should give 280 mg at 10 A.M. Using the formula of 75 mg/kg/day, 75 mg (15 kg = 1125 mg per day, to be divided into 4 doses. 1125 mg divided by 4 doses = 280 mg per dose. Use basic math. Do not forget to divide the daily dose of 1125 mg by the total number of doses per day to get the amount to be given for a single dose at 10:00 A.M. A 4-year-old patient is scheduled for repair of a left undescended testicle. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this patient, in which position should the nurse place him? Prone with legs abducted. Sitting on a potty seat. Supine with foot of bed elevated. Side-lying with upper leg flexed. The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child. If the child were to lie prone (Answer 1), the nurse could not administer the medication as safely or effectively, even if the legs were abducted; further, this position would most likely cause the child some discomfort. If the child were sitting on a potty scat (Answer 2), the nurse could not reach the rectum to insert the suppository, and it is likely the suppository would be immediately expelled. If the child were to lie supine (Answer 3), the nurse could not administer the medication comfortably for the child. Do not use "real world" experience to Answer this question (i.e., how you may have seen a mother do it!) Visualize the positions; then choose one based on patient comfort and nursing effectiveness. A 4-year-old boy appears very anxious and frightened before receiving a rectal suppository as a preoperative medication. Which statement by the nurse would be most appropriate in helping the child take this medication? Be a big kid! Everyone's waiting for you. You look so scared. Want to know a secret? This won't hurt a bit! Lie still now and I'll let you have one of your presents before you even have your operation. Take a nice, big, deep breath and then let me hear you count to five. Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempt to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the bullocks together to prevent expulsion of the suppository. The nurse should not pressure the child into acting like a "big kid" (Answer 1) in such a frightening situation (use of the word "kid" is also not appropriate). The nurse should not lie, breaking a trust by saying something "won't hurt a bit" (Answer 2). The nurse should never "bribe" a child with gifts to ensure cooperation (Answer 3). Maximize patient control over the situation and use age-appropriate distraction techniques. A 4-year-old patient is scheduled for surgery. In preparing this child's preop injections, which size needle should the nurse select to administer this child's IM injection? 25 G, 5/8inch. 22 G, 1 inch. 20 G, 1 inch. 18 G, 1 inch. In selecting the correct needle to administer an IM injection to a young child, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. A medium-gauge needle (22 G) that is 1 inch long would be most appropriate for a young child. A % inch needle (Answer 1) would be too small, and a 1 1/2 inch (18-20 G) needle would be too long and unnecessarily large (Answers 3,4). A 23 or 25 G needle would be too thin to use on most children (Answer 1) and would be better suited for use with a newborn or an infant. Visualize the "average" size of a 4-year-old. Medium size is safe. Meperidine hydrochloride (Demerol) would be preferred over morphine sulfate for a patient with a chest tube because Demerol: Causes less nausea and vomiting. Reduces anxiety and respiratory rate more effectively. Causes less smooth muscle spasms. Causes less respiratory depression. Both drugs have depressant effects; however, morphine sulfate affects rate and depth of respirations and cough reflex, which would be undesirable following chest tube insertion. Both drugs cause nausea and vomiting (Answer 1). Morphine sulfate is used to reduce anxiety and respiratory rate (Answer 2), particularly in pulmonary edema. Demerol does cause fewer smooth muscle spasms (Answer 3); however, that is not the concern in this situation, but it would be with GI surgery such as cholecystectomy. Choose "respiratory" over GI symptoms, anxiety, or muscle spasm. Know expected effects of opioid analgesics, and what the greatest concern is for this patient situation (respiratory effectiveness). A patient with diabetes has been giving herself NPH and regular insulin daily in two separate injections. The nurse would be accurate in telling the patient that: One injection, mixing the insulins, is safe, and injection sites will be used less. Her method is the best way to ensure accurate administration. It does not really make any difference if she uses one or two syringes. More mistakes are made when mixing insulins. Regular and intermediate-acting insulins are normally mixed to avoid the need to use injection sites twice as often. Rotation of sites is important, and the same site should not be used more often than every 2 to 4 weeks to avoid the development of lipodystrophies. Answer 2 may ensure accuracy; however, it is not standard practice or necessary. Although not unsafe, use of two syringes does increase the potential for lipodystrophy; therefore, it does make a difference (Answer 3). There is no evidence that more errors are made when insulin types are mixed (Answer 4). Know the "clear to cloudy" rule with V mixing insulins; therefore, one syringe is all you need. Before administering a blood transfusion, the tubing should be flushed with: 1. 5% dextrose in water. Dextran. 3. 5% dextrose, 0.5 normal saline. Lactated Ringer's. Blood and a solution containing glucose (dextrose) will result in precipitation when mixed outside the body. Saline is often the solution of choice. However, lactated Ringer's, an electrolyte-balanced solution without dextrose, is acceptable. Answers 1,2, and 3 contain glucose (dextrose). Look for patterns in the options. Three of the choices contain dextrose. Choose the one that does not. Which patient information, documented during an assessment, would be a contraindication to the patient receiving verapamil (Calan)? Epigastric pain and treatment for a peptic ulcer. Hypertension and angina on exertion. History of asthma and allergic bronchitis. Hypotension associated with bradycardia. Verapamil, a calcium channel blocker, is indicated for the management of hypertension and arrhythmia with rapid ventricular rates. Blood pressure and pulse should be taken before administration, and the medication would most likely be held or changed with persistent hypotension and bradycardia. Answers 1,2, and 3 would not be contraindications; the medication may be given to patients with these existing conditions. To narrow the choices, focus on two contradictory options: hypertension vs. hypotension. Know expected therapeutic and side effects of drug classifications. A patient is receiving heparin IV for acute thrombophlebitis The activated partial thromboplastin time (APTT) is > 110 sec. The best nursing action would be to: Stop the heparin infusion. Give protamine sulfate. Call the MD to report the APTT. Do nothing; this is the desired level. The APTT is greater than 3 times the normal level. Therapeutic levels are 1.5 to 2.3 times the normal (control) level. With a potential medical emergency, the nurse must notify the MD; care decisions are collaborative. Answers 1 and 2 are not independent nursing actions. Answer 4 is incorrect and could be life threatening for the patient. Focus on two contradictory options: "do nothing" vs. "call the MD." Know normal laboratory values and expected therapeutic levels and realize this is an "Oh! Oh!" situation. A transfusion reaction is suspected. The transfusion is stopped and the MD notified. The next appropriate nursing action would be to: Change all IV tubing to prevent additional infusion of blood cells. Keep the IV line open with saline until further orders. Arrange for the laboratory to pick up the remaining unit of blood. Collect a urine specimen from the patient. The priority is to keep the IV site open. Medications may need to be given to reverse the patient's untoward reaction to the transfusion. Answers 1,3, and 4 will eventually be done, but not before the patency of the IV is determined and maintained. Take care of the patient's safety first, then changing the equipment and laboratory tests. A patient with a history of arthritis and peptic ulcer disease is receiving misoprostol (Cytotec). Patient teaching about the drug would include: Take the medication three times a day before meals and at bedtime. Importance of using this drug when NSAIDs are also being taken by the patient. Purpose of drug is to reduce H. pylori bacteria in the stomach. Take a laxative to prevent side effect of constipation. Cytotec prevents gastric mucosal injury related to chronic NSAID therapy in high-risk patients (elderly, debilitated, or history of ulcers). The medication is taken with meals, not before (Answer 1). The drug has no effect on H. pylori(Answer 3). The drug decreases gastric acid secretion and increases production of protective mucus. A side effect of the drug is diarrhea, not constipation (Answer 4). Look for clues in the stem (a possible link between arthritis and ulcer disease). Magnesium hydroxide (Milk of Magnesia) is the routine laxative order to prevent or correct constipation. For which patient would the nurse question the order? An elderly woman with potential for fecal impaction. A patient with chronic renal failure who is admitted for shunt revision. A male patient who is recovering from total knee replacement. An older male patient who is being treated for pneumonia. Metabolism and excretion of the drug are done primarily by the kidneys. In chronic renal failure, the kidneys would be unable to regulate electrolyte balance and the patient would be at higher risk for the development of an electrolyte imbalance. Another classification of laxative should be used in the renal patient. This laxative is not contraindicated for others (Answers 1,3, and 4). Use the process of elimination. Would an electrolyte-based laxative (magnesium) adversely affect one of these patients more? A patient is admitted to the emergency department (FD) in acute distress from asthma. Theophylline and 5% dextrose are being infused IV. The patient is experiencing hypotension and an irregular pulse. The first nursing action would be to: Stop the medication and call the ED physician. Check the BP and pulse frequently while the drug infuses. Increase IV rate to reverse possible hypovolemia. Slow infusion rate and notify the ED physician. Hypotension and arrhythmias are expected side effects of too-rapid administration of theophylline or aminophylline. An infusion pump should be used for administration to ensure an accurate and safe dosage. Answer 1 is not appropriate because the drug is needed to improve breathing. Answer 2 is incorrect because it does not respond to the side effects. Answer 3 would increase the adverse drug effects. Before contacting the MD, look for a nursing action that ensures patient safety. The choice is between "stop" or "slow" before calling the MD. Choose "slow," because "stop" may stop the benefit of this drug (to improve breathing). A patient's laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions should the nurse anticipate will be ordered as the most appropriate during initial fluid replacement therapy? 10% dextrose and saline. 5% dextrose and water with 60 mEq KC1. 5% dextrose and water only. Distilled water. Initial fluid therapy is directed toward increasing fluid volume and urine output. Answer 1, being a hypertonic solution that would act to increase intracellular dehydration, is therefore contraindicated. Once adequate urinary output has been established, potassium salts are added (Answer 2) to relieve hypokalemia. The amount of added potassium chloride depends on the extent of hypokalemia. Answer 4, distilled water, is a hypotonic solution; that is, it does not contain any additional electrolytes. Hypotonic solutions, such as 0.45% sodium chloride, are frequently given to relieve hypertonic syndromes. However, distilled water is never given in fluid replacement therapy The key word is initial. Use H20 to replace fluid loss. Focus on two similar options that have 5% D/W (2,3). Eliminate the option with KCl (1) because it is added later. Before surgery, a patient was instructed in the use of an incentive spirometer. The primary purpose of this activity is: To encourage coughing. To arouse and stimulate the patient. To encourage deep breathing. To measure tidal volume and expiratory reserve volume. The purpose of the incentive spirometer is to encourage deep breathing. The patient is able to directly visualize progress by the number and height of balls he or she is able to raise. Aftereffects of this activity may indeed be coughing up sputum (Answer 1) and arousal (Answer 2) as the patient competes with himself or herself. Incentive spirometry can be used as a rough measure of tidal volume and expiratory reserve volume (Answer 4) because the patient breathes in deeply and exhales completely into the incentive spirometer Key word is primary (or first) purpose. Patients are first taught to deep breathe. The nurse explains to a patient's family that humidification is given with oxygen administration because: Oxygen is highly permeable in water, thereby increasing gaseous diffusion. Oxygen is very drying to the mucous membranes. The partial pressures of oxygen are increased by water dilution, allowing more oxygen to reach the alveoli. Water acts as a carrier substance facilitating movement of oxygen across the respiratory membrane. Humidification of oxygen is extremely important in reducing its drying effects on the mucous membranes of the bronchial tree. Humidification of oxygen is generally provided by a water nebulizer. Answers 1,3, and 4 are incorrect because oxygen is not highly permeable in water; thus, water tends to inhibit rather than facilitate oxygen diffusion across the respiratory membrane. Humidification expands the volume of the inhaled gas, but by doing so it decreases the partial pressure of the gas in the alveoli. Normal alveolar partial pressures of oxygen are approximately 100 mm Hg, whereas the partial pressures of oxygen in the atmosphere are approximately 135 mm Hg The question is asking why 02 is given with humidification. Look for a simple answer. Humidification provides moisture because 02 is drying. The nurse would conclude that a patient's fasting serum-glucose levels are normal if the results are: 30-60 mg/dL of blood. 80-126 mg/dL of blood. 126-140 md/dL of blood. 140-200 mg/dL of blood. Normal fasting serumglucose levels are 80126 mg/dL of blood. Levels below 60 (Answer 1) indicate hypoglycemia; levels above 126 mg/dL (Answers 3,4) indicate hyperglycemia Key term is normal. First eliminate the extreme numbers (too low and too high). "Normal" tends to be a lowmidpoint value. A laboratory test to measure serum- and urine-glucose levels before and after ingestion of a glucose load has been ordered. The nurse knows that the test to be done is called: Fasting blood sugar. Glucose tolerance test. Postprandial blood glucose. Tolbutamide response test. Procedurally, the patient to receive the glucose tolerance test consumes a high-carbohydrate diet for 3 days before the test. All drugs that may influence the test are discontinued during this period (oral contraceptives, aspirin, and steroids). On the day of the test, fasting blood (Answer 1) and urine specimens are collected before the test, to provide control glucose levels. After ingestion of a glucose load, specimens of blood and urine are collected at hourly intervals for 3 hours. In diabetes mellitus, glucose levels are elevated. The postprandial blood glucose (Answer 3) is determined by giving the patient an oral glucose load only. Blood-glucose levels are then evaluated in 2 hours. Usually glucose levels will return to normal during this period of time. The tolbutamide response test (Answer 4) may also be used to confirm diabetes. After the patient fasts overnight, a baseline fasting blood sample is drawn. Intravenous tolbutamide is then given, and blood samples are drawn in 20-30 minutes. After this test the patient should be given orange juice and instructed to eat breakfast Key phrase is before and after; FBS (1) is done only before. Postprandial means after a meal. Glucose tolerance (2) has both SL "before" and an "after" component. After a glucose tolerance test, the nurse would look for the blood-glucose levels to return to normal in about how many hours? One. Two. Three. Four. Within 3 hours the patient's serum-glucose levels should not only have returned to normal, but some hypoglycemia should be expected. Answers 1,2, and 4 are incorrect Eliminate the extremes (1,4). Recall that the procedure calls for 3 days of high carbohydrate; you will make a good guess by selecting 3 hours. Following a gastroscopy, the nurse will plan to offer the patient food or fluid: As soon as he or she returns to the room. One hour later, or after he or she is fully alert. Three to 4 hours later, or when the gag reflex returns. Six to 8 hours later to prevent the electrolyte imbalance that may occur with this procedure. Following gastroscopy, food and fluids are withheld until the gag reflex returns (generally 2-3 hours) in order to prevent aspiration. The gag reflex is inactivated by either an anesthetic spray or an oral preparation gargled by the patient before insertion of the gastroscopy tube. Inhibition of the gag reflex facilitates insertion. Answers 1 and 2 are incorrect because the period of time is too brief. Answer 4 is incorrect not only because it is generally unnecessary to wait 6-8 hours for the gag reflex to return, but because this procedure does not precipitate an electrolyte imbalance Note that timeframe is key here. Eliminate the extremes (1,2 are too soon; 4 is too long, as well as an incorrect reason). The nurse knows that a 24-hour urine-for-creatinine clearance measures which of the following kidney functions? Filtration fraction. Glomerular filtration rate. Renal blood flow. Quantity and specific gravity of urinary output. Decreased amounts of creatinine in the urine are a reflection of the glomerular filtration rate, indicating the ability of the kidney to clear the renal blood of this substance. The filtration fraction is simply the amount of glomerular filtrate entering the tubules (Answer 1). Renal blood flow is estimated by measuring renal excretion of para-aminohippuric acid (PAH) (Answer 3). Though the amount and specific gravity of urine may be determined, it is not the primary function of this laboratory test (Answer 4) Key words in the stem: measure kidney functions, meaning measure kidney's ability to "do its job," i.e., to clear (filter). Choose 2 over 1 (both options have "filtration") because 1 is the amount entering. A patient asks why an intravenous pyelogram (IVP) is being done. The nurse tells the patient the purpose is to: Determine the size, shape, and placement of the kidneys. Test renal tubular function and the patency of the urinary tract. Measure renal blood flow. Outline the kidney vasculature. Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium. Answer 1 is an example of a KUB. or flat plate of the abdomen, which can reveal gross structural changes in the kidneys and urethra. Renal blood flow (Answer 3) is determined by the injection of para-aminohippuric acid (PAH) and measurement of its excretion in the urine. Answer 4 is an example of renal angiogram Match other common renal system tests (KUB, PAH, renal angiogram) with the descriptions, to identify one that does not fit. Choose the option that describes a test that gives more than anatomical information (eliminate 1,4). Answer 2 provides more data (tubular function and patency of urinary tract) than Answer 3 (blood flow). The nursing care of a patient before an IVP includes: Telling the patient that the contrast medium may produce a warm, flushed feeling in the face and a salty taste in the mouth. Administering radiopaque capsules 6 hours before the test. Ascertaining whether or not the patient has any allergies to mercury. Pushing fluids until 2 hours before the test, to prevent dehydration. Patent teaching includes telling the patient that a warm, flushed sensation and salty taste may occur from the contrast medium. The contrast medium is given by IV injection during the procedure, not in capsule form (Answer 2). Answer 3 is incorrect because allergies to iodine, not to mercury, are the concern. Fluids are not pushed before this procedure; they are withheld for up to 8 hours before testing, to produce a slight dehydration that aids in concentrating the contrast medium in the kidneys and urinary system (Answer 4) Eliminate Answer 2 because the test is done intravenously (intravenous pyelogram), not with capsules. Eliminate Answer 3 because the potential allergy is to iodine. Eliminate Answer 4 because the opposite is needed for the test. The nurse's preparation of the patient undergoing IV cholangiogram includes: Administering radiopaque tablets the evening before the examination. A fatty meal the evening before the examination. Forcing fluids for 6-8 hours before the examination. Informing the patient that he or she may experience a feeling of warmth, flushing of face, and/or a salty taste when the contrast medium is injected. The patient is informed of possible reaction to injection of the contrast medium, which is administered by an IV injection at the time of the test, not by tablets the evening before (Answer 1). Answer 2 is incorrect because if patients are given anything by mouth they are given a low-fat meal the evening before IV cholangiogram or oral cholecystogram. The patient is usually quite ill at this time and may not be able to tolerate oral intake. In order to have a clear visualization of the gallbladder, the bowel is cleansed, and food and fluids are withheld, not forced (Answer 3), for 6-8 hours. Note the name of the procedure: IV cholangiogram, meaning that the contrast medium will be injected. Eliminate the three other options that refer to oral intake. The nurse knows that the most important effect of intermittent positive-pressure breathing (IPPB) is: Mobilization of bronchial secretions. Increased alveolar ventilation. Prevention of atelectasis. Decreased airway resistance. The most important effect of intermittent positive-pressure breathing (IPPB) is increased alveolar ventilation. It also helps mobilize secretions (Answer 1), decrease the occurrence of atelectasis (Answer 3), and decrease airway resistance (Answer 4) through mechanical bronchodilation When all options are correct, choose the one (alveolar ventilation) that encompasses the three other effects.