Exam 3 Questions

Question 1

The patient is incontinent, and a condom catheter is placed. The nurse should take which action?

1. Secure the condom with adhesive tape
2. Change the condom every 48 hours
3. Assess the patient for skin irritation
4. Use sterile technique for placement

Answer 1

Assess the patient for skin irritation

Skin irritation can occur when the condom is twisted at the drainage tube attachment and obstructs urine drainage.

Question 1

The nurse working in the recovery room is caring for a patient who had a radical neck dissection. The nurse notices that the patient has a coarse, high-pitched sound on inspiration. Which of the following is the appropriate intervention by the nurse?

a) Notifying the physician
b) Administering a breathing treatment
c) Documenting the presence of stridor
d) Lowering the head of the bed

Answer 1

a) Notifying the physician

Explanation:

The presence of stridor, a coarse, high-pitched sound on inspiration, in the immediate postoperative period following radical neck dissection indicates obstruction of the airway and requires that the nurse report it immediately to the physician.

Question 1

The nurse in the ED admits a patient with suspected gastric outlet obstruction. The patient’s symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which of the following orders?

a) Nasogastric (NG) tube insertion
b) Oral contrast
c) Stool specimen
d) Pelvic x-ray

Answer 1

a) Nasogastric (NG) tube insertion

Explanation:

The nurse anticipates an order for NG tube insertion to decompress the stomach. Pelvic x-ray, oral contrast, and stool specimens are not indicated at this time

Question 2

he nurse is preparing to assess a patient’s newly created stoma. Which of the following findings would the nurse include in the documentation of a healthy stoma?

a) Dry in appearance
b) Pink color
c) Pain
d) Black color

Answer 2

b)Pink color

Explanation:

Characteristics of a healthy stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. A black color may indicate necrosis of the stoma, which may require surgical intervention.

Question 2

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?

a) Minimize intake of caffeine, beer, milk, and foods containing peppermint and spearmint.
b) Avoid eating or drinking 2 hours before bedtime.
c) Elevate the foot of the bed on 6- to 8-inch blocks.
d) Eat a low-carbohydrate diet.

Answer 2

b) Avoid eating or drinking 2 hours before bedtime.

Explanation:

The patient should not recline with a full stomach. The patient should be instructed to avoid the listed foods and food components. The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. The patient is instructed to eat a low-fat diet.

Question 3

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:

1. Addiction.
2. Tolerance.
3. Pseudoaddiction.
4. Physical dependence.

Answer 3

Physical dependence.

Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Question 4

A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following?

a) Tolerance
b) Dependence
c) Addiction
d) Placebo effect

Answer 4

c) Addiction

Explanation:

Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties.

Question 4

A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:

1. “Let’s talk about something cheerful.”
2. “Do other members of your family have diabetes?”
3. “I can tell that you feel stressed to learn that you have diabetes.”
4. With silence.

Answer 4

With silence.

The nurse understands that denial is a defense mechanism that assists in coping with a shock. Therapeutic use of silence gives patients time to process their thoughts.

Question 4

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching?

1. “I won’t put the baby to bed with a bottle.”
2. “For the first few weeks we’re putting the cradle in our room.”
3. “My grandmother told me that babies sleep better on their stomachs.”
4. “I know I’ll have to get up during the night to feed the baby when he wakes up.”

Answer 4

“My grandmother told me that babies sleep better on their stomachs.”

Thinking that babies will sleep better on their stomachs indicates that the mother needs further teaching. She needs to be educated on the “back to bed” concept for infant sleeping. Infants’ beds need to be safe. Parents should place infants on their back to prevent suffocation and decrease the risk of sudden infant death syndrome (SIDS).

Question 4

The nurse notes that the patient’s Foley catheter bag has been empty for 4 hours. The priority action would be to:

1. Irrigate the Foley.
2. Check for kinks in the tubing.
3. Notify the health care provider.
4. Assess the patient’s intake.

Answer 4

Check for kinks in the tubing.

Kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing.

Question 4

The nurse is assessing the skin graft site of a patient who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which of the following?

a) Healthy graft
b) Infection of graft
c) Venous congestion of graft
d) Possible necrosis of graft

Answer 4

a) Healthy graft

Explanation:

A healthy graft site is pink and warm to the touch. A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion

Question 5

A crisis intervention nurse working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her entitlement check while the child is hospitalized can expect the mother to regain stability after how long?

1. After 2 weeks when the child’s pneumonia begins to improve
2. After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks
3. After 1 month when the child goes home and the mother gets help from a food pantry
4. After 6 months when the child is back in school

Answer 5

After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks

Generally a person resolves the crisis and reaches psychological equilibrium in about 6 weeks.

Question 5

The nurse is conducting discharge teaching for a patient who was admitted with a kidney stone. The nurse includes which of the following as a measure to prevent additional kidney stones?

a) Adhere to a low-calcium diet.
b) Increase protein intake.
c) Avoid drinking tea.
d) Avoid drinking water before bedtime.

Answer 5

c)Avoid drinking tea.

Explanation:

The nurse should teach the patient to avoid tea and other oxalate-containing foods, such as spinach, strawberries, rhubarb, peanuts, and wheat bran. The patient should restrict protein intake to 60 g/day and should drink two glasses of water at bedtime. Low-calcium diets are generally not recommended.

Question 6

Postoperatively, a patient with a radical neck dissection should be placed in which position?

a) Side-lying
b) Fowler’s
c) Supine
d) Prone

Answer 6

b) Fowler’s

Explanation:

The patient should be placed in the Fowler’s position to facilitate expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

Question 7

The nurse is documenting that a patient has an inflammation of the salivary glands. The nurse documents which of the following findings?

a) Sialadenitis
b) Stomatitis
c) Pyosis
d) Parotitis

Answer 7

a) Sialadenitis

Explanation:

Sialadenitis is the inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus

Question 7

The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program?

a) The incidence of colorectal cancer decreases with age.
b) It is the third most common cancer in the United States.
c) The lifetime risk of developing colorectal cancer is 1 in 10.
d) There is no hereditary component to colorectal cancer.

Answer 7

b) It is the third most common cancer in the United States.

Explanation:

Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.

Question 8

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

a) Hypoglycemia
b) Polydipsia
c) Polyuria
d) Blurred vision

Answer 8

a) Hypoglycemia

Explanation:

The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

Question 8

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:

Help him stand to void.

Place a condom catheter.

Have him practice Credé’s method.

Initiate Kegel exercises.

Answer 8

Initiate Kegel exercises.

Kegel exercises strengthen pelvic floor muscles and are effective in urine control in patients with urge incontinence and difficulty starting and stopping urination.

Question 9

The nurse is conducting a history and assessment related to a patient’s incontinence. Which of the following should the nurse include in the assessment before beginning a bladder training program?

a) Occupational history
b) History of allergies
c) Smoking habits
d) Medication usage

Answer 9

d)Medication usage

Explanation:

It is essential to assess the patient’s physical and environmental conditions before beginning a bladder training program, because the patient may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the patient. It is not so essential to assess the patient’s history of allergy, occupation, and smoking habits before beginning a bladder training program.

Question 10

A home health nurse is visiting a patient who has been taking the same dose of hydrocodone/acetaminophen (Lortab) for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the patient?

a) Observe respiratory rate and depth.
b) Ask about the patient’s bowel pattern.
c) Take the patient’s blood pressure.
d) Assess level of consciousness.

Answer 10

b) Ask about the patient’s bowel pattern.

Explanation:

Opioids can result in delayed gastric emptying, slowed bowel motility, and decreased peristalsis, all of which result in slow-moving, hard stool that is difficult to pass. Constipation is a very common side effect of narcotics that continues to be a problem, even with chronic administration. Although respiratory depression, decreased level of consciousness, and hypotension are common side effects of acute use of narcotics, these effects are not expected to occur with chronic usage at the same dose.

Question 10

Which of the following would be included in the teaching plan for a patient diagnosed with diabetes mellitus?

a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision.
b) The only diet change needed in the treatment of diabetes is to stop eating sugar.
c) Sugar is found only in dessert foods.
d) Once insulin injections are started in the treatment of type 2 diabetes, they can never be discontinued.

Answer 10

a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision.

Explanation:

Diabetic retinopathy is the leading cause of blindness among people between 20 and 74 years of age in the United States; it occurs in both type 1 and type 2 diabetes. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Question 11

What is the most common cause of small-bowel obstruction?

a) Neoplasms
b) Adhesions
c) Volvulus
d) Hernias

Answer 11

b) Adhesions

Explanation:

Adhesions are scar tissue that forms as a result of inflammation and infection. Adhesions are the most common cause of small-bowel obstruction, followed by hernias and neoplasms. Other causes include intussusceptions, volvulus, and paralytic ileus.

Question 12

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which of the following actions illustrates the nociception process of pain transmission?

a) mother in labor utilizing imagery to reduce pain
b) A patient taking tramadol (Ultram) to enhance pain management
c) A surgeon making an incision to perform surgery
d) A child quickly removing a hand when touching a hot object

Answer 12

d) A child quickly removing a hand when touching a hot object

Explanation:

Transduction, the first process involved in nociception, refers to the processes by which noxious stimuli, such as a surgical incision, release of a number of excitatory compounds which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual mechanism analgesic agent, such as tramadol (Ultram), involves many different neurochemicals as in the process of modulation.

Question 13

The nurse is conducting a community education program on stress. The nurse includes which of the following?

a) Effective stress adaptation is a disease precursor.
b) Short-term stress increases susceptibility to disease.
c) Stressors elicit a state of homeostasis.
d) Excessive stress response increases susceptibility to illness.

Answer 13

d) Excessive stress response increases susceptibility to illness.

Explanation:

Excessive stress response and long-term stress increase an individual’s susceptibility to illness. Stressors elicit a state of disturbed physiologic equilibrium. Stress and maladaptation are precursors to disease.

Question 13

A high school football player hurts his foot while playing a game. He complains of intense pain with muscle spasms and swelling of the toe. Which of the following pain assessment tools will the nurse most likely use to assess the patient’s pain level? a) Verbal Descriptor Scales (VDS) b) Visual Analog Scale (VAS) c) Wong-Baker FACES Pain Rating Scale d) Numeric Rating Scale (NRS)

Answer 13

d) Numeric Rating Scale (NRS) Explanation: The NRS is most appropriate for this patient. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the patient’s ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.

Question 13

A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, “You look anorexic.” Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition? a) "Your body is using protein and fat for energy instead of glucose." b) "You may be having undiagnosed infections causing you to lose extra weight." c) “Don’t worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism.” d) "I will refer you to a dietician who can help you with your weight."

Answer 13

a) "Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

Question 14

Studying for the NCLEX-RN examination is an example of which type of stressor? a) Stressor sequence b) Chronic intermittent c) Acute, time limited d) Chronic enduring

Answer 14

c) Acute, time limited ## Footnote Explanation: An acute, time-limited stressor includes studying for final examinations, such as the NCLEX-RN examination. A stressor sequence is a series of stressful events that results from an initial event such as a job loss or divorce. Chronic intermittent stressors consist of daily stressors. A chronic enduring stressor is a stressor that persists over time, such as chronic illness, disability, or poverty.

Question 14

The nurse is teaching the Benson Relaxation Response to a patient for stress reduction. The nurse instructs the patient to do which of the following? a) Practice the technique daily b) Select a focus word c) Maintain an active demeanor d) Think of a comforting scene

Answer 14

b) Select a focus word ## Footnote Explanation: The nurse should instruct the patient to select a focus word, maintain a passive demeanor, and practice the technique twice daily. Thinking of a comforting scene is a part of guided imagery

Question 14

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Stool softener 2. Stimulant laxative 3. H 2 receptor blocker 4. Proton pump inhibitor

Answer 14

Stimulant laxative Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation.

Question 15

For which of the following reasons are nonpharmacologic pain management techniques employed? Select all that apply. a) They lower the risk of patients' becoming addicted to pain medications. b) They help decrease the distress the patient experiences from pain. c) They help decrease the sensation of pain. d) They can successfully replace pain medications. e) They allow patients to match the technique to their own individual and cultural preferences.

Answer 15

b) They help decrease the distress the patient experiences from pain. c) They help decrease the sensation of pain. e) They allow patients to match the technique to their own individual and cultural preferences. Explanation: Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the patient experiences from pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods. Many patients find that the use of nonpharmacologic methods helps them cope better with their pain and feel greater control over the pain. Nonpharmacologic methods do not have any relationship to a patient’s risk of becoming addicted to pain medications. A variety of techniques allows them to match the technique to their own individual and cultural preferences.

Question 15

The nurse is creating a discharge plan of care for a patient with a peptic ulcer. The nurse tells the patient to avoid which of the following? a) Decaffeinated coffee b) Tylenol c) Skim milk d) Octreotide

Answer 15

a) Decaffeinated coffee ## Footnote Explanation: The nurse should include avoidance of decaffeinated coffee in the patient’s discharge teaching plan. Decaffeinated coffee is avoided to keep from overstimulating acid secretio

Question 16

The nurse is administering lispro (Humalog) insulin. Based on the onset of action, how soon should the nurse administer the injection prior to breakfast? a) 1 to 2 hours b) 10 to 15 minutes c) 3 hours d) 30 to 40 minutes

Answer 16

b) 10 to 15 minutes Explanation: The onset of action of rapid-acting Humalog is within 10 to 15 minutes. It is used for rapid reduction of glucose level.

Question 17

A patient with type 1 diabetes mellitus is being taught about self-injection of insulin. Which of the following facts about site rotation should the nurse include in the teaching? a) Avoid the abdomen because absorption there is irregular. b) Use all available injection sites within one area. c) Rotate sites from area to area every other day. d) Choose a different site at random for each injection.

Answer 17

b) Use all available injection sites within one area. Explanation: Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.

Question 17

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which of the following? a) Anal fistula b) Hemorrhoid c) Anal fissure d) Anorectal abscess

Answer 17

c) Anal fissure ## Footnote Explanation: Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

Question 17

The nurse is assisting a patient to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve? a) 5 in. b) 6 in. c) 2 in. d) 3 in.

Answer 17

c) 2 in. ## Footnote Explanation: The nurse should insert the lubricated catheter about 2 in. (5 cm) through the nipple/valve

Question 18

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: 1. Cystitis. 2. Hematuria. 3. Pyelonephritis. 4. Dysuria.

Answer 18

Cystitis. Urine is cloudy in cystitis because of bacterial and white cells.

Question 20

The advance practice nurse is treating a patient experiencing a neuropathic pain syndrome. Which of the following statements when made by the patient demonstrates an understanding of concepts related to neuropathic pain? a) “Neuropathic pain is the body’s normal response to tissue damage causing pain.” b) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.” c) “When the inflammation in my foot resolves I will no longer have pain from neuropathy.” d) “Neuropathic pain will only last a few days and is easily treated with COX-2 analgesic agents.”

Answer 20

b) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.” Explanation: Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the TCAs despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment.

Question 20

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts? a) 100 mL b) 30 mL c) 400 mL d) 50 mL

Answer 20

a)100 mL Explanation: Residual urine that is less than 100 mL indicates that the suprapubic catheter cannot be discontinued. If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Question 20

The nurse is preparing to assess the donor site of a patient who underwent a myocutaneous flap after a radical neck dissection. The nurse prepares to assess the most commonly used muscle for this surgery. Which of the following muscles should the nurse assess? a) Bicep b) Pectoralis major c) Trapezius d) Sternomastoid

Answer 20

b) Pectoralis major ## Footnote Explanation: The most common donor site for a myocutaneous flap after radical neck dissection is the pectoralis major muscle, so the nurse should prepare to assess this site unless a different donor site is documented on the patient’s chart.

Question 21

Which of the following should be included in the teaching plan for a patient receiving glargine (Lantus), "peakless" basal insulin? a) It is rapidly absorbed, has a fast onset of action. b) Do not mix with other insulins. c) Draw up the drug first, then add regular insulin. d) Administer the total daily dosage in two doses.

Answer 21

b) Do not mix with other insulins. Explanation: Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Question 21

The nurse is teaching a patient about self-administration of insulin and mixing of regular and neutral protamine Hagedorn (NPH) insulin. Which of the following is important to include in the teaching plan? a) If two different types of insulin are ordered, they need to be given in separate injections. b) There is no longer a need to inject air into the bottle of insulin before insulin is withdrawn. c) When mixing insulin, the regular insulin is drawn up into the syringe first. d) When mixing insulin, the NPH insulin is drawn up into the syringe first.

Answer 21

c) When mixing insulin, the regular insulin is drawn up into the syringe first. Explanation: When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before drawing into the syringe. The American Diabetic Association (ADA) recommends that the regular insulin be drawn up first. The most important issues are (1) that patients are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) that patients not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.

Question 22

The nurse is caring for a patient after bariatric surgery who experiences symptoms of gastric outlet obstruction. Which of the following are contraindicated? a) Surgical revision b) Endoscopic procedure c) NG tube d) Balloon dilation

Answer 22

c) NG tube ## Footnote Explanation: NG tube insertion is contraindicated in patients who have had bariatric surgery. Alternative treatment options include endoscopic procedures, balloon dilation, and/or surgical revision

Question 23

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? 1. “I’ll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear.” 2. “Sleep medicines won’t cause any sleep problems once I stop taking them.” 3. “I’ll talk to my health care provider before I use an over the- counter sleep medication.” 4. “I’ll contact my health care provider if I feel extreme sleepy in the mornings.”

Answer 23

“I’ll talk to my health care provider before I use an over the- counter sleep medication.” Talking to a health care provider before using an over-the-counter sleep medication shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption, even when they initially seemed to be effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action, which can cause confusion, constipation, urinary retention, and increased risk of falls.

Question 24

The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions? a) Ulcerative colitis b) Intestinal malabsorption c) Small-bowel disease d) Disorders of the colon

Answer 24

a) Ulcerative colitis ## Footnote Explanation: The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.

Question 25

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high? a) Hyperactivity b) Blurred vision c) Increased energy d) Oliguria

Answer 25

b) Blurred vision Explanation: Blurred vision occurs when the blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.

Question 25

The postoperative patient has difficulty voiding after surgery and is feeling “uncomfortable” in the lower abdomen. Which action should the nurse implement first? Encourage fluid intake Administer pain medication Catheterize the patient Turn on the bathroom faucet as he tries to void

Answer 25

Turn on the bathroom faucet as he tries to void The sound of running water helps many patients to void through the power of suggestion.

Question 26

The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase? 1. REM sleep 2. Stage 1 NREM sleep 3. Stage 4 NREM sleep 4. Transition period from NREM to REM sleep

Answer 26

REM sleep Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe they are functionally important to learning, memory processing, and adaptation to stress.

Question 27

The nurse is caring for an older patient whose chart reveals that the patient has a reversible cause of urinary incontinence. The nurse creates a plan of care for which of the following conditions? a) Bladder cancer b) Asthma c) Decreased progesterone levels d) Constipation

Answer 27

d)Constipation Explanation: Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased fluid intake, a change in a chronic disease pattern, and decreased estrogen levels in the menopausal woman. The other answers do not apply.

Question 27

Crohn’s disease is a condition of malabsorption caused by which of the following pathophysiological processes? a) Infectious disease b) Gastric resection c) Inflammation of all layers of intestinal mucosa d) Disaccharidase deficiency

Answer 27

c) Inflammation of all layers of intestinal mucosa ## Footnote Explanation: Crohn’s disease, also known as regional enteritis, can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.

Question 29

Which of the following statements when made by a cancer patient with moderate-to-severe pain prescribed oxymorphone (Opana IR) indicates further instruction is required? a) “The IR indicates I will get fast relief when I take the medication.” b) “I will stop drinking beer while I’m on this medication.” c) “I can also have this medication in an extended release tablet.” d) “I will take this medication with breakfast for the best results.”

Answer 29

d) “I will take this medication with breakfast for the best results.” Explanation: Oxymorphone (Opana IR) must be taken on an empty stomach (1 hour before or 2 hours after a meal). Co-ingestion of alcohol can increase the serum concentration of the drug. Oxymorphone has been available for many years in parenteral formulation and more recently in short-acting (Opana IR) and modified-release (Opana ER) oral tablets.

Question 30

A patient has been prescribed a Fentanyl patch for pain control. The nurse understands that this patch should be replaced how often? a) Every 48 hours b) Every 24 hours c) Every 72 hours d) Every 36 hours

Answer 30

c) Every 72 hours Explanation: Fentanyl patches should be replaced every 72 hours. The other timeframes are incorrect.

Question 31

Which of the following statements correctly identifies a difference between duodenal and gastric ulcers? a) Weight gain may occur with a gastric ulcer. b) A gastric ulcer is caused by hypersecretion of stomach acid. c) Vomiting is uncommon in patients with duodenal ulcers. d) Malignancy is associated with duodenal ulcer.

Answer 31

c) Vomiting is uncommon in patients with duodenal ulcers. ## Footnote Explanation: Vomiting is uncommon in patients diagnosed with duodenal ulcer. Malignancy is associated with a gastric ulcer. Weight gain may occur with a duodenal ulcer. Duodenal ulcers cause hypersecretion of stomach acid.

Question 32

Which of the following is a true statement regarding placebos? a) A placebo should never be used to test the person's truthfulness about pain. b) A positive response to a placebo indicates that the person’s pain is not real. c) A placebo effect is an indication that the person does not have pain. d) A placebo should be used as the first line of treatment for the patient.

Answer 32

a) A placebo should never be used to test the person's truthfulness about pain. Explanation: Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person’s pain is not real.

Question 32

A patient is admitted with diabetic ketoacidosis (DKA). The physician writes all of the following orders. Which order should the nurse implement first? a) Infuse 0.9% normal saline solution 1 L/hr for 2 hours. b) Administer regular insulin 30 U IV push. c) Start an infusion of regular insulin at 50 U/hr. d) Administer sodium bicarbonate 50 mEq IV push.

Answer 32

a) Infuse 0.9% normal saline solution 1 L/hr for 2 hours. Explanation: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated patients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.

Question 32

The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem? 1. Nocturia 2. Hyperactivity 3. Grogginess and feeling hung over 4. Increased sleep time

Answer 32

Grogginess and feeling hung over Benzodiazepines cause a hangover effect and rebound insomnia. The other sleep problems are not related to benzodiazepines.

Question 33

The nurse is working with a patient who is in a stressful situation. The nurse evaluates the patient’s resiliency by assessing the patient’s ability to do which of the following? a) Continue to function well b) Admit past mistakes c) Respond with strong emotions d) Verbalize feelings of anger

Answer 33

a) Continue to function well ## Footnote Explanation: Resilience has been defined by researchers as the ability of a person to function well in stressful situations. It is demonstrated by controlling strong emotional reactions, using appropriate communication and problem-solving skills as well as knowing when to take action, when to rely on others, and when to nurture self.

Question 34

A 1,200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The nurse is teaching the patient about meal planning using exchange lists. The teaching is determined to be effective based on which of the following statements? a) “For dinner I ate 2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda.” b) “For dinner I ate 2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas and garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon.” c) “For dinner I ate 4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion, 1 ounce low-fat cheese, 1 tablespoon mayonnaise, 1 cup fresh strawberry shortcake, and unsweetened iced tea.” d) “For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda.”

Answer 34

d) “For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda.” Explanation: There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. Example: 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1¼ cup watermelon; “free” items like diet soda are optional.

Question 35

A 60-year-old patient comes to the ED with complaints of weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the patient has diabetes. Which of the following classic symptoms should the nurse watch for to confirm the diagnosis of diabetes? a) Numbness b) Fatigue c) Dizziness d) Increased hunger

Answer 35

d) Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

Question 35

The nurse caring for a patient after urinary diversion surgery monitors the patient closely for peritonitis by assessing for which of the following? Select all that apply. a) Muscle flaccidity b) Leukocytosis c) Abdominal distention d) Hyperactive bowel sounds

Answer 35

b)Leukocytosis, c)Abdominal distention Explanation:The nurse should monitor the patient for the following signs and symptoms of peritonitis: leukocytosis, abdominal distention, absence of bowel sounds, fever, muscle rigidity, guarding, and nausea and vomiting

Question 36

The advance nurse practitioner treating a patient diagnosed with neuropathic pain decides to start adjuvant analgesic agent therapy. Which of the following medications is appropriate for the nurse practitioner to prescribe? a) Tramadol (Ultracet) b) Gabapentin (Neurontin) c) Hydromorphone (Dilaudid) d) Ketamine (Ketalar)

Answer 36

b) Gabapentin (Neurontin) Explanation: The anticonvulsants gabapentin (Neurontin) is a first-line analgesic agent for neuropathic pain. Tramadol (Ultracet) is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine (Ketalar) is used as a third-line analgesic agent for refractory acute pain. Hydromorphone (Dilaudid) is a first-line opioid not used as an analgesic agent for neuropathic pain.

Question 36

The nurse is planning care for a patient with painful oral lesions. Which of the following should be included in the patient’s diet? a) Pretzels b) Jello c) Chili d) Hot tea

Answer 36

b) Jello ## Footnote Explanation: The nurse should include Jello in the patient’s diet; spicy, hot, and/or hard foods or beverages (pretzels, hot tea, chili) should be avoided to reduce pain and discomfort in the patient with painful oral lesions.

Question 37

If an indwelling catheter is necessary, which of the following nursing interventions should be implemented to prevent infection? a) Placing the catheter bag on the patient's abdomen when moving the patient b) Using sterile technique to disconnect the catheter from tubing to obtain urine specimens c) Using clean technique during insertion d) Performing meticulous perineal care daily with soap and water

Answer 37

d)Performing meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used during insertion of a urinary bladder catheter. The nurse must maintain a closed system and use the catheter’s port to obtain specimens. The catheter bag must never be placed on the patient’s abdomen unless it is clamped because it may cause backflow of urine from the tubing into the bladder.

Question 37

Which of the following is an accurate statement regarding cancer of the esophagus? a) It is seen more frequently in Caucasian Americans than in African Americans. b) It is three times more common in women in the United States than men. c) It usually occurs in the fourth decade of life. d) Chronic irritation of the esophagus is a known risk factor.

Answer 37

d) Chronic irritation of the esophagus is a known risk factor. ## Footnote Explanation: In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life.

Question 39

Progressive muscle relaxation, relaxation with guided imagery, and the Benson Relaxation Response share which of the following elements? a) Analgesic preparation b) Nutritional foundation c) A mental device (something on which to focus the attention) d) Physician’s order

Answer 39

c) A mental device (something on which to focus the attention) ## Footnote Explanation: Relaxation techniques do not encompass specific nutritional guidelines. Relaxation techniques are used to reduce a response to stress and do not require analgesia prior to practicing the techniques. A physician's order is not required to assist an individual in learning techniques to reduce his or her response to stress.

Question 40

Which of the following medications may be ordered to relieve discomfort associated with a UTI? a) Ciprofloxacin (Cipro) b) Phenazopyridine (Pyridium) c) Nitrofurantoin (Furadantin) d) Levofloxacin (Levaquin)

Answer 40

b)Phenazopyridine (Pyridium) Explanation: Pyridium is a urinary analgesic ordered to relieve discomfort associated with UTIs. Furadantin, Cipro, and Levaquin are antibiotics.

Question 41

The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which of the following as a contributing factor for UTIs in older adults? a) Active lifestyle b) Sporadic use of antimicrobial agents c) Low incidence of chronic illness d) Immunocompromise

Answer 41

d)Immunocompromise Explanation:Factors that contribute to UTIs in older adults include immunocompromise, high incidence of chronic illness, immobility, and frequent use of antimicrobial agents

Question 42

A patient newly diagnosed with type 1 diabetes has an unusual increase in blood glucose from bedtime to morning. The physician suspects the patient is experiencing insulin waning. Based on this diagnosis, the nurse will expect which of the following changes to the patient’s medication regimen? a) Changing the time of injection of evening intermediate-acting insulin from dinnertime to bedtime b) Decreasing evening bedtime dose of intermediate-acting insulin and administering a bedtime snack c) Increasing morning dose of long-acting insulin d) Administering a dose of intermediate-acting insulin before the evening meal

Answer 42

d) Administering a dose of intermediate-acting insulin before the evening meal Explanation: Insulin waning is a progressive rise in blood glucose form bedtime to morning. Treatment includes increasing the evening (predinner or bedtime) dose of intermediate-acting or long-acting insulin or instituting a dose of insulin before the evening meal if that is not already part of the treatment regimen.

Question 42

Which of the following terms is used to refer to inflammation of the renal pelvis? a) Urethritis b) Cystitis c) Interstitial nephritis d) Pyelonephritis

Answer 42

d)Pyelonephritis Explanation: Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.

Question 44

The preferred route of administration of medication in the most acute care situations is through which of the following routes? a) Intramuscular b) Epidural c) Intravenous (IV) d) Subcutaneous

Answer 44

c) Intravenous (IV) Explanation: IV is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than IV-administered medication.

Question 45

Prostaglandins are chemical substances with which of the following properties? a) Reduction of the perception of pain b) Inhibition of the transmission of noxious stimuli c) Increased sensitivity of pain receptors d) Inhibition of the transmission of pain

Answer 45

c) Increased sensitivity of pain receptors Explanation: Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Question 45

Which of the following is the primary symptom of achalasia? a) Chest pain b) Heartburn c) Pulmonary symptoms d) Difficulty swallowing

Answer 45

d) Difficulty swallowing ## Footnote Explanation: The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The patient may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

Question 46

When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point? a) There are no administration requirements b) At the same time the first patch is applied c) Immediately following the morning shower d) Prior to respiratory assessment

Answer 46

b) At the same time the first patch is applied Explanation: The skin must be clean and dry prior to patch application; no shower is required. Respiratory assessment must be conducted prior to applying the fentanyl patch. Because it takes 12 to 24 hours for the fentanyl levels to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The other time frames are incorrect.

Question 47

The nurse is monitoring a patient’s postoperative course after an appendectomy. The nurse’s assessment reveals that the patient has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse’s report to the physician is that the patient has signs/symptoms of which of the following complications? a) Peritonitis b) Ileus c) Hemorrhage d) Pelvic abscess

Answer 47

a) Peritonitis ## Footnote Explanation: The nurse should report to the physician that the patient has signs/symptoms of peritonitis. Signs/symptoms of a pelvic abscess include anorexia, chills, fever, diaphoresis, and diarrhea. Signs/symptoms of an ileus include absent bowel sounds, nausea, and abdominal distention. Signs/symptoms of hemorrhage include tachycardia, hypotension, anxiety, and bleeding.

Question 49

Which of the following is the most common presenting symptom of colon cancer? a) Weight loss b) Anorexia c) Change in bowel habits d) Fatigue

Answer 49

c) Change in bowel habits ## Footnote Explanation: The most common presenting symptom is a change in bowel habits. Fatigue, anorexia, and weight loss may occur, but none of these is the most common presenting symptom

Question 50

The nurse working in the ED is evaluating a patient for signs and symptoms of appendicitis. Which of the patient’s signs/symptoms should the nurse include in the report to the physician on the patient’s signs/symptoms of appendicitis? a) Nausea b) High fever c) Pain when pressure is applied to the right lower quadrant of the abdomen d) Left lower quadrant pain

Answer 50

a) Nausea ## Footnote Explanation: Nausea is typically associated with appendicitis with or without vomiting. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt with release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.

Question 51

Which type of medication may be used in the treatment of a patient with incontinence to inhibit contraction of the bladder? a) Anticholinergic agent b) Tricyclic antidepressants c) Over-the-counter decongestant d) Estrogen hormone

Answer 51

a)Anticholinergic agent Explanation: Anticholinergic agents are considered first-line medications for urge incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Tricyclic antidepressants decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine and phenylpropanolamine, ingredients found in over-the-counter decongestants.

Question 52

When a person who has been taking opioids becomes less sensitive to the drug’s analgesic properties, that person is said to have developed which of the following? a) A tolerance b) A dependence c) A balanced analgesia d) An addiction

Answer 52

a) A tolerance Explanation: Tolerance is characterized by the need for increasing dose requirements to maintain the same level of pain relief. Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Balanced analgesia occurs when the patient is using more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.

Question 53

The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) 1. Note any allergies. 2. Monitor intake and output. 3. Provide for perineal hygiene. 4. Assess vital signs. 5. Encourage fluids after the procedure.

Answer 53

Note any allergies. Encourage fluids after the procedure.

Question 54

The nurse is creating a plan of care for a patient who is not able to tolerate brushing his teeth. The nurse includes in the plan of care which of the following mouth irrigations? a) Mouthwash and water b) Baking soda and water c) Full-strength peroxide d) Dextrose and water

Answer 54

b) Baking soda and water ## Footnote Explanation: When a patient is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp of baking soda to 8 oz of warm water, half-strength hydrogen peroxide, or normal saline solution

Question 55

During which phase of the general adaptation syndrome is the “fight or flight” response activated? a) Exhaustion b) Alarm c) Inflammatory d) Resistance

Answer 55

b) Alarm ## Footnote Explanation: The alarm reaction is defensive and anti-inflammatory, but self-limiting. During the resistance stage, adaptation to the noxious stressor occurs and cortisol activity is still increased. The inflammatory state is not part of the general adaptation syndrome. During the exhaustion stage, endocrine activity increases, which has negative effects on the body systems that can lead to death.

Question 56

A patient with type 2 diabetes has recently been placed on acarbose (Precose); the nurse is explaining how to take this medication. The teaching is determined to be effective based on which of the following statements? a) “This medication needs to be taken after the midday meal.” b) “It does not matter what time of day I take this medication.” c) “I will take this medication in the morning, with my first bite of breakfast.” d) “I will take this medication in the morning, 15 minutes before breakfast.”

Answer 56

c) “I will take this medication in the morning, with my first bite of breakfast.” Explanation: Alpha-glucosidase inhibitors, such as acarbose (Precose) and miglitol (Glyset), delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.

Question 57

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? 1. Loss of autonomy caused by health problems 2. Physical appearance, family, friends, and school 3. Self-esteem issues, changing family structure 4. Search for identity with peer groups and separating from family

Answer 57

Search for identity with peer groups and separating from family Search for identity with peer groups and separating from family are stressors most commonly experienced by adolescents. Loss of autonomy caused by health problems applies to the older adult. Physical appearance, family, friends and school apply to children. Self-esteem issues and a changing family structure apply to preadolescents.

Question 58

When taking a patient history, the nurse notes that the patient has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the patient is experiencing which of the following types of pain after an amputation? a) Acute pain b) Phantom pain c) Breakthrough pain d) Chronic pain

Answer 58

d) Chronic pain Explanation: Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by patients with a normally controlled pain management regimen. Patients who have a history of amputation commonly report phantom pain in the amputated extremity.

Question 58

Which action by the nursing assistant at bedtime requires the nurse to intervene? 1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient’s room 4. Giving a patient a cup of coffee

Answer 58

Giving a patient a cup of coffee Encourage patients not to drink or ingest caffeine before bedtime. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.

Question 60

The nurse working with a patient after an ileal conduit notices that the pouching system is leaking small amounts of urine. The appropriate nursing intervention is which of the following? a) Empty the pouch. b) Secure/patch it with tape. c) Change wafer and pouch. d) Secure/patch with barrier paste.

Answer 60

c)Change wafer and pouch. Explanation:Whenever the nurse notes a leaking pouching system, the nurse should change the wafer and pouch. Attempting to secure or patch the leak with tape and/or barrier paste will trap urine under the barrier or faceplate, which will compromise peristomal skin integrity. Emptying the pouch will not rectify the leaking

Question 61

What pain assessment scale would be best to use with a 5-year-old child? a) A pain assessment scale is inappropriate for a 5-year-old child. b) A Numerical Pain Scale c) The FACES scale d) A Visual Analog Scale

Answer 61

c) The FACES scale Explanation: The FACES scale was developed for use in children. It consists of six pictures depicting faces ranging from content to distressed. The child points to the face that best shows how much he or she hurts. The FACES scale may also be useful for adults who have difficulty with numerical or visual analog scales. Specific pain assessment scales have been tested for use in many patient populations from neonates to patients who have dementia. The Visual Analog Scale and Numerical Pain Scale are not the best choices for a 5-year-old because they depend on the patient being able to read and use numbers.

Question 61

The nurse is caring for a patient during the postoperative period following radical neck dissection. Which of the following should be reported to the physician? a) High epigastric pain and/or discomfort b) Crackles that clear after coughing c) Serous drainage on the dressing d) Temperature of 99.0ºF

Answer 61

a) High epigastric pain and/or discomfort ## Footnote Explanation: The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0ºF are normal findings in the immediate postoperative period and do not require reporting to the physician.

Question 62

The nurse is reinforcing diet teaching for a patient s diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet? a) Fluids with meals b) Caffeinated products c) Spicy foods d) High-fiber diet

Answer 62

d) High-fiber diet ## Footnote Explanation: A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants, such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, and alcohol, should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

Question 63

Which type of diarrhea is caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen? a) Diarrheal disease b) Osmotic diarrhea c) Secretory diarrhea d) Mixed diarrhea

Answer 63

c) Secretory diarrhea ## Footnote Explanation: Secretory diarrhea is usually high-volume diarrhea caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen. Osmotic diarrhea occurs when water is pulled into the intestines by the osmotic pressure of nonabsorbed particles, slowing the reabsorption of water. Mixed diarrhea is caused by increased peristalsis (usually from inflammatory bowel disease) and a combination of increased secretion or decreased absorption in the bowel. The most common cause of diarrheal disease is contaminated food.

Question 64

The nurse is teaching a patient on preventing dysphagia after bariatric surgery. The nurse tells the patient to avoid which of the following? Select all that apply. a) Cheese b) Peas c) Doughy bread d) Steak

Answer 64

c) Doughy bread, d) Steak ## Footnote Explanation: The nurse should include in the teaching the avoidance of eating tough foods, such as steak as well as doughy bread. Patients should also be instructed to eat slowly and to chew their food thoroughly

Question 66

Which of the following would be included in a teaching plan for a patient diagnosed with a UTI? a) Drink liberal amount of fluids. b) Drink coffee or tea to increase diuresis. c) Use tub baths as opposed to showers. d) Void every 4 to 6 hours.

Answer 66

a)Drink liberal amount of fluids. Explanation: Patients diagnosed with a UTI should drink liberal amounts of fluids. They should void every 2 to 3 hours. Coffee and tea are urinary irritants. The patient should shower instead of bathing in a tub because bacteria in the bath water may enter the urethra.

Question 67

A patient undergoes surgery for removing a malignant tumor, followed by a urinary diversion procedure. The nurse’s postoperative plan of care should include which of the following? a) Suggest a visit to a local ostomy group. b) Show pictures and drawings of placement of the stoma. c) Determine the patient’s ability to manage stoma care. d) Maintain skin and stomal integrity.

Answer 67

d)Maintain skin and stomal integrity. Explanation: The most important postoperative nursing management is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor. Determining the patient’s ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.

Question 68

Which intervention is appropriate to include on a care plan for improving sleep in the older adult? 1. Decrease fluids 2 to 4 hours before sleep 2. Exercise in the evening to increase fatigue 3. Allow the patient to sleep as late as possible 4. Take a nap during the day to make up for lost sleep

Answer 68

Decrease fluids 2 to 4 hours before sleep Decreasing fluids 2 to 4 hours before sleep reduces the likelihood that the older adult’s sleep will be disrupted during the night by the need to void.

Question 68

Which type of incontinency refers to the involuntary loss of urine due to medications? a) Iatrogenic b) Urge c) Reflex d) Overflow

Answer 68

a)Iatrogenic Explanation: Iatrogenic incontinence is the involuntary loss of urine due to medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.

Question 69

The nurse is creating a discharge teaching plan for a patient post surgery for oral cancer. Which of the following should be included in the teaching plan? Select all that apply. a) Follow-up medical appointment b) Use of humidification c) Follow-up dental appointment d) Oral hygiene

Answer 69

a) Follow-up medical appointment, b) Use of humidification, c) Follow-up dental appointment, d) Oral hygiene ## Footnote Explanation: Discharge teaching for a patient after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist

Question 71

About which of the following issues should the nurse inform patients who use pain medications on a regular basis? a) Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. b) Minimize the intake of fiber during the therapy. c) Consume the medications just before or along with meals. d) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician.

Answer 71

d) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician. Explanation: Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. OCT analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

Question 72

The nurse is caring for a client with hypoxia. The nurse understands that brain cell death may occur in a little as how many minutes? a) 1 to 3 b) 3 to 6 c) 6 to 9 d) 9 to 12

Answer 72

b) 3 to 6 ## Footnote Explanation: The length of time that different tissues can survive without oxygen varies. Brain cells may succumb in 3 to 6 minutes, depending on the situation

Question 73

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? 1. Results in neurophysiological response. 2. Reduces body temperature 3. Causes a person to be hypervigilant 4. Reduces level of consciousness to conserve energy.

Answer 73

Results in neurophysiological response. Negative feedback senses an abnormal state such as lowered body temperature and makes an adaptive response such as shivering to generate body heat to return the body to hormonal homeostasis.

Question 74

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

Answer 74

A thorough physical assessment Physical causes for problems need to be discovered before treatment for psychosocial problems can be initiated.

Question 75

The nurse is gathering a sleep history from a patient who is being evaluated for obstructive sleep apnea. Which common symptoms does the patient most likely report? (Select all that apply.) 1. Headache 2. Early wakening 3. Excessive daytime sleepiness 4. Difficulty falling asleep 5. Snoring

Answer 75

Headache, Excessive daytime sleepiness, Snoring

Question 77

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient’s wife says that he can’t be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1. The patient’s wife is the best resource for determining the level of pain since she has been with him continually for the entire day. 2. The patient’s report of pain is the best method for assessing the pain. 3. The patient’s health care provider has the best knowledge of the level of pain that the patient that should be experiencing. 4. The nurse is the most experienced at assessing pain.

Answer 77

The patient’s report of pain is the best method for assessing the pain. A patient’s self-report of pain is the single most reliable indicator of the existence and intensity of pain.

Question 78

The most common symptom of esophageal disease is which of the following? a) Odynophagia b) Vomiting c) Nausea d) Dysphagia

Answer 78

d) Dysphagia ## Footnote Explanation: Dysphagia may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing. Nausea is the most common symptom of GI problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain on swallowing.

Question 79

The nurse is assessing a patient with progressive gastric cancer. The nurse anticipates that the assessment will reveal which of the following findings? a) Increased appetite b) Weight gain c) Abdominal pain below umbilicus d) Bloating after meals

Answer 79

d) Bloating after meals ## Footnote Explanation: Symptoms of progressive disease include bloating after meals, weight loss, abdominal pain above the umbilicus, and loss or decrease in appetite

Question 81

A patient with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestations associated with this classic symptom? a) Altered mental state b) Muscle wasting and tissue loss c) Dehydration d) Weight gain

Answer 81

b) Muscle wasting and tissue loss Explanation: Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although people with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.

Question 82

A patient who had bariatric surgery complains of diarrhea. The nurse recommends which of the following dietary changes? a) Increased fiber b) Decreased fat c) Decreased carbohydrates d) Increased protein

Answer 82

a) Increased fiber ## Footnote Explanation: The nurse recommends that the patient increase fiber in the diet because a high-fiber diet can decrease both diarrhea and constipation after bariatric surgery.

Question 83

Which of the following, approved by the United States Food and Drug Administration, is the only use for lidocaine 5% patch (Lidoderm)? a) Postherpetic neuralgia b) Diabetic neuropathy c) Epidural anesthesia d) General anesthesia

Answer 83

a) Postherpetic neuralgia Explanation: A lidocaine 5% (Lidoderm) patch has been shown to be effective in postherpetic neuralgia. Lidoderm has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

Question 85

A patient with an esophageal disorder comes into the hospital with symptoms that include halitosis and a sour taste in the mouth. These symptoms are associated most directly with which of the following? a) Achalasia b) Hiatal hernia c) Esophageal diverticula d) Gastroesophageal reflux

Answer 85

c) Esophageal diverticula ## Footnote Explanation: Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints. Achalasia presents as difficulty in swallowing both liquids and solids. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in, or pain upon, swallowing. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients, whereas at least 50% of patients are asymptomatic.

Question 86

A patient with gastro esophageal reflux disease (GERD) comes to the physician’s office with complaints of a burning sensation in the esophagus. The nurse documents that the patient is experiencing which of the following? a) Dyspepsia b) Pyrosis c) Dysphagia d) Odynophagia

Answer 86

b) Pyrosis ## Footnote Explanation: Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia

Question 88

A nursing student is getting ready to take a final exam. Based on the understanding of the sympathetic nervous system’s response to stress, which assessment finding will be noted? A.Hot, sweaty skin B.Rapid respirations C.Decreased heart rate D.Skeletal muscle relaxation

Answer 88

B. Rapid respirations Rationale: Common assessment findings with the sympathetic nervous system’s response to stress are **cold, clammy skin; increased heart rate; rapid respirations; and skeletal muscle tension.**

Question 89

About which of the following issues should the nurse inform patients who use pain medications on a regular basis? a) Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. b) Minimize the intake of fiber during the therapy. c) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician. d) Consume the medications just before or along with meals.

Answer 89

c) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician. Explanation: Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. OCT analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

Question 90

A nurse observes that a patient whose home life is chaotic with intermittent homelessness, a child with spina bifida, and an abusive spouse appears to be experiencing an allostatic load. As a result, the nurse expects to detect which of the following while assessing the patient? 1. Posttraumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal

Answer 90

Chronic illness An increased allopathic load can result in long-term physiological problems and chronic illness. Posttraumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage. Vital signs return to normal in the resistance stage.

Question 92

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. I always feel tired when I wake up in the morning. 2. I go to bed at the same time each night. 3. It takes me about 15 minutes to fall asleep. 4. Sometimes I have to get up during the night to urinate.

Answer 92

I always feel tired when I wake up in the morning. This statement indicates that the patient is not experiencing quality sleep and should be followed up with more extensive questions and assessment of the problem. Patients are the best resource for describing sleep problems and how these problems are a change from their usual sleep and waking patterns. A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin you need to understand the nature of the sleep problem, its signs and symptoms, its onset and duration, its severity, any predisposing factors or causes, and the overall effect on the patient. Ask specific questions related to the sleep problem.

Question 94

Which nursing measure best promotes sleep in a school-age child? 1. Encourage evening exercise 2. Offer a glass of hot chocolate before bedtime 3. Make sure that the room is dark and quiet 4. Use quiet activities consistently before bedtime

Answer 94

Use quiet activities consistently before bedtime A bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) used consistently helps young children avoid delaying sleep. Quiet activities such as reading stories, coloring, and allowing children to sit in a parent’s lap while listening to music or a prayer are routines that are often associated with preparing for bed. Parents need to reinforce patterns of preparing for bedtime.

Question 94

The nurse in the ED is admitting a patient with bloody stools. The nurse documents this finding as being which of the following? a) Steatorrhea b) Melena c) Tarry stools d) Hematochezia

Answer 94

d) Hematochezia ## Footnote Explanation: The nurse should document the finding of bloody stools as hematochezia. Melena is the term used for tarry black stools with occult blood. Steatorrhea is the term utilized for fatty stools that have an oily appearance and float in water.

Question 96

The nurse is using progressive muscle relaxation with a patient to reduce stress. The nurse instructs the patient to do which of the following? a) Stand in a quiet, darkened area b) Tense and relax specific muscles c) Select a pleasant scene d) Repeat a word or phrase

Answer 96

b) Tense and relax specific muscles ## Footnote Explanation: During progressive muscle relaxation, the patient lies in a quiet room and tenses the muscles of the body one at a time. The person holds the tension and then relaxes. Repetition of a word or phrase is used in the Benson Relaxation Response and selection of a pleasant scene is used in guided imagery.

Question 98

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which of the following as being a type of premalignant squamous cell skin cancer? a) Actinic cheilitis b) Krythoplakia c) Chancre d) Herpes simplex 1

Answer 98

a) Actinic cheilitis ## Footnote Explanation: Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of horny layers of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed patients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Krythoplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.

Question 99

Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

Answer 99

Difficulty arousing the patient Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.

Question 100

The nurse is assessing an 80-year-old patient for signs and symptoms of gastric cancer. The nurse differentiates which of the following to be a sign/symptom of gastric cancer in the geriatric patient, but not in a patient under the age of 75? a) Hepatomegalia b) Agitation c) Ascites d) Abdominal mass

Answer 100

b) Agitation ## Footnote Explanation: The nurse differentiates that agitation, along with confusion and restlessness, may be the only signs/symptoms seen of gastric cancer in the older patient. Abdominal mass, hepatomegaly, and ascites may all be signs/symptoms of advanced gastric cancer.

Question 101

Prostaglandins are chemical substances with which of the following properties? a) Reduction of the perception of pain b) Increased sensitivity of pain receptors c) Inhibition of the transmission of noxious stimuli d) Inhibition of the transmission of pain

Answer 101

b) Increased sensitivity of pain receptors Explanation: Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Question 103

A nurse is preparing to discharge a patient with coronary artery disease (CAD) and hypertension (HTN) who is at risk for type 2 diabetes. Which of the following information is important to include in the discharge teaching? a) How to monitor ketones daily b) How to recognize signs of diabetic ketoacidosis (DKA) c) How to control blood glucose through lifestyle modification with diet and exercise d) How to self-inject insulin

Answer 103

c) How to control blood glucose through lifestyle modification with diet and exercise Explanation: Persons at high risk for type 2 diabetes receive standard lifestyle recommendations plus metformin, standard lifestyle recommendations plus placebo, or an intensive program of lifestyle modifications. The 16-lesson curriculum of the intensive program of lifestyle modifications focuses on weight reduction of greater than 7% of initial body weight and physical activity of moderate intensity. It also includes behavior modification strategies designed to help patients achieve the goals of weight reduction and participation in exercise. These findings demonstrate that type 2 diabetes can be prevented or delayed in persons at high risk for the disease.

Question 104

The nurse is conducting a community education program on urinary incontinence. The nurse determines that the participants understand the teaching when they identify which of the following as risk factors for urinary incontinence? a) Body mass index (BMI) of 22 b) Cesarean delivery c) Swimming d) Sedatives

Answer 104

d)Sedatives Explanation:Use of sedatives, diuretics, hypnotics, and opioids are risk factors for urinary incontinence. Additional risk factors include high-impact exercises, a BMI greater than 40, and vaginal birth delivery

Question 105

During a follow-up visit 3 months following a new diagnosis of type 2 diabetes, a patient reports exercising and following a reduced-calorie diet. Assessment reveals that the patient has only lost 1 pound and did not bring the glucose-monitoring record. Which of the following tests will the nurse plan to obtain? a) Glycosylated hemoglobin level b) Fasting blood glucose level c) Oral glucose tolerance test d) Urine dipstick for glucose

Answer 105

a) Glycosylated hemoglobin level Explanation: Glycosylated hemoglobin is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months. When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes.

Question 106

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse’s first response is which of the following? 1. “Don’t be sad. People live with cancer every day.” 2. “Have you thought about how you are going to tell your family?” 3. “Would you like for me to sit down with you for a few minutes so you can talk about this?” 4. “I know another patient whose colon cancer was cured by surgery.”

Answer 106

“Would you like for me to sit down with you for a few minutes so you can talk about this?” Ask the patient if he would like you to sit down for a few minutes so he can talk. Providing an open-ended question and an opportunity for the patient to talk allows the nurse to assess the patient’s perception of the situation, which is of utmost importance.

Question 107

Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.) 1. Incontinence 2. Frequency 3. Urgency 4. Urinary retention 5. Urinary tract infection

Answer 107

Incontinence Frequency Urgency Urinary retention Urinary tract infection

Question 108

A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.) 1. Infection. 2. Retention. 3. Stagnant urine. 4. Reflux of urine.

Answer 108

Infection. Reflux of urine.

Question 110

The most common presenting objective symptoms of a UTI in older adults, especially in those with dementia, include which of the following? a) Hematuria b) Incontinence c) Change in cognitive functioning d) Back pain

Question 111

Which of the following may be a potential cause of hypoglycemia in the patient diagnosed with diabetes mellitus? a) The patient has not consumed food and continues to take insulin or oral antidiabetic medications. b) The patient has not been exercising. c) The patient has consumed food and has not taken or received insulin. d) The patient has not been compliant with the prescribed treatment regimen.

Answer 111

a) The patient has not consumed food and continues to take insulin or oral antidiabetic medications. Explanation: Hypoglycemia in patients is usually the result of too much insulin or delays in eating.

Question 113

Which of the following is a true statement regarding gastric cancer? a) The prognosis for gastric cancer is good. b) Most cases are discovered prior to metastasis. c) Women have a higher incidence of gastric cancer. d) Most patients are asymptomatic during the early stage of the disease.

Answer 113

d) Most patients are asymptomatic during the early stage of the disease. ## Footnote Explanation: Most patients are asymptomatic during the early stage of the disease. Men have a higher incidence of gastric cancer than women. The prognosis is poor because the diagnosis is usually made late because most patients are asymptomatic during the early stage. Most cases of gastric cancer are discovered only after local invasion has advanced or metastases are present.

Question 115

The nurse conducting a community educational program on stress is including Lazarus’s cognitive appraisal theory. The nurse evaluates that the participants understand the teaching when they state that during primary appraisal which of the following occurs? a) Evaluation of what might be done b) Conflict between desire and need c) Identification of the event as stressful d) Changing a previous opinion

Answer 115

c) Identification of the event as stressful ## Footnote Explanation: During primary appraisal the event is evaluated with respect to what is at stake and results in the situation being identified as either nonstressful or stressful. Evaluation of what might be done occurs during secondary appraisal.

Question 117

A patient receives a daily injection of glargine (Lantus) insulin at 7:00 am. When should the nurse monitor this patient for a hypoglycemic reaction? a) Between 8:00 and 10:00 am b) This insulin has no peak action and does not cause a hypoglycemic reaction. c) Between 7:00 and 9:00 pm d) Between 4:00 and 6:00 pm

Answer 117

b) This insulin has no peak action and does not cause a hypoglycemic reaction. Explanation: Peakless basal or very long-acting insulins are approved by the Food and Drug Administration for use as a basal insulin—that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. It has is no peak action.

Question 118

Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: 1. Cause headaches and nausea. 2. Be expensive and difficult to obtain. 3. Cause severe depression and anxiety. 4. Lead to sleep disruption.

Answer 118

Lead to sleep disruption. Long-term use of sleeping medications in older adults can lead to sleep disruption. Because of slower metabolism and excretion of sleep medications, the potential for sleep impairment occurs. If sleep medications are needed, the lowest dose possible should be used short term.

Question 119

Which of the following terms, according to Lazarus, refers to the process through which an event is evaluated with respect to what is at stake and what might and can be done? a) Adaptation b) Coping c) Cognitive appraisal d) Hardiness

Answer 119

c) Cognitive appraisal ## Footnote Explanation: The outcome of cognitive appraisal is identification of the situation as either stressful or not stressful. Coping consists of both cognitive and behavioral efforts made to manage the specific external or internal demand that taxes a person's resources. Hardiness is a personality characteristic that is composed of control, commitment, and challenge. Lazarus believed adaptation was affected by emotion that subsumed stress and coping.

Question 121

During the assessment interview of an older woman experiencing a developmental crisis, the nurse asks which of the following questions? 1. How is this flood affecting your life? 2. Since your husband has died, what have you been doing in the evening when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help.

Answer 121

Since your husband has died, what have you been doing in the evening when you feel lonely? A developmental crisis occurs as a person moves through life’s stages, including widowhood.

Question 122

The nurse caring for a patient with a urinary diversion notices mucus around the stents and in the patient’s urine. The appropriate nursing intervention is to do which of the following? a) Document presence of mucus in the urine. b) Remove the urinary stents. c) Contact the physician. d) Document the separation of the mucocutaneous junction.

Answer 122

a)Document presence of mucus in the urine. Explanation: The nurse should document the presence of mucus in the urine as this is a normal finding in urinary diversions.

Question 123

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which of the following diseases/conditions? a) Pernicious anemia b) Peptic ulcers c) Colostomy d) Systemic infection

Answer 123

c) Peptic ulcers ## Footnote Explanation: Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

Question 124

A 34-year-old man who is anxious, tearful, and tired from caring for his three young children tells you that he feels depressed and doesn’t see how he can go on much longer. Your best response would be which of the following? “Are you thinking of suicide?” “You’ve been doing a good job raising your children. You can do it!” “Is there someone who can help you?” “You have so much to live for.”

Answer 124

“Are you thinking of suicide?” Although this sounds abrupt, the patient usually is relieved that you’ve broached this issue. For safety reasons it is very important to discuss his suicidal thoughts with the patient.

Question 126

The advance practice nurse is treating a patient experiencing a neuropathic pain syndrome. Which of the following statements when made by the patient demonstrates an understanding of concepts related to neuropathic pain? a) “When the inflammation in my foot resolves I will no longer have pain from neuropathy.” b) “Neuropathic pain is the body’s normal response to tissue damage causing pain.” c) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.” d) “Neuropathic pain will only last a few days and is easily treated with COX-2 analgesic agents.”

Answer 126

c) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.” Explanation: Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the TCAs despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment.

Question 127

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

Answer 127

The time interval Controlled- or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.

Question 128

The nurse caring for an elderly patient diagnosed with diarrhea is administering and monitoring the patient’s medications. Because one of the patient’s medications is digitalis (digoxin [Lanoxin]), the nurse monitors the patient closely for which of the following? a) Hypernatremia b) Hypokalemia c) Hyperkalemia d) Hyponatremia

Answer 128

b) Hypokalemia ## Footnote Explanation: The older person taking digoxin must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

Question 129

Which of the following is a true statement regarding regional enteritis (Crohn’s disease)? a) It has a progressive disease pattern. b) The clusters of ulcers take on a cobblestone appearance. c) It is characterized by lower left quadrant abdominal pain. d) The lesions are in continuous contact with one another.

Answer 129

b) The clusters of ulcers take on a cobblestone appearance. ## Footnote Explanation: The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.

Question 131

The nurse is assessing a patient for constipation. Which of the following is the first factor the nurse should review to identify the cause of constipation? a) Current medications b) Alcohol consumption c) Usual pattern of elimination d) Activity levels

Answer 131

c) Usual pattern of elimination ## Footnote Explanation: Constipation has many possible reasons and assessing the patient’s usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the patient's current medications, diet, and activity levels.

Question 132

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the patient is coping successfully when the patient says: 1. “I’m going to learn to drive a car so I can be more independent.” 2. “My sister says she feels better when she goes shopping, so I’ll go shopping.” 3. “I’ve always felt better when I go for a long walk. I’ll do that when I get home.” 4. “I’ m going to attend a support group to learn more about multiple sclerosis.”

Answer 132

“I’ m going to attend a support group to learn more about multiple sclerosis.” Support groups often benefit people experiencing stress.

Question 134

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? 1. Suggest he stand at the bedside 2. Stay with the patient 3. Give him the urinal to use in bed 4. Tell him that, if he doesn’t urinate, he will be catheterized

Answer 134

Suggest he stand at the bedside A man voids more easily in the standing position

Question 136

Since removal of the patient’s Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? 1. Check for bladder distention 2. Encourage fluid intake 3. Obtain an order to recatheterize the patient 4. Document the amount of each voiding for 24 hours

Answer 136

Check for bladder distention The patient may experience urinary retention after catheter removal. If amounts voided are small, checking for bladder distention is necessary.

Question 137

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. The supervising nurse recognizes that: 1. Nurses who feel stress usually pass the stress along to their patients. 2. A nurse who feels stress is ineffective as a nurse and should not be working. 3. Nurses who talk about feeling stress are unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.

Answer 137

Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring and when the situation seems out of their personal control.

Question 138

A health care provider writes the following order for an opioidnaive patient who returned from the operating room following a total hip replacement. “Fentanyl patch 100 mcg, change every 3 days.” Based on this order, the nurse takes the following action: 1. Calls the health care provider, and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

Answer 138

Calls the health care provider, and questions the order Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.

Question 139

After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 139

1320 mL

Question 140

Which of the following is considered a stimulant laxative? a) Bisacodyl (Dulcolax) b) Mineral oil c) Psyllium hydrophilic mucilloid (Metamucil) d) Magnesium hydroxide (Milk of Magnesia)

Answer 140

a) Bisacodyl (Dulcolax) ## Footnote Explanation: Dulcolax is a stimulant laxative. Milk of Magnesia is a saline agent. Mineral oil is a lubricant. Metamucil is a bulk-forming agent

Question 141

Which of the following nursing interventions should a nurse perform when caring for a patient who is prescribed opiate therapy for pain? a) Do not administer if respirations are less than 12 per minute. b) Monitor weight, vital signs, and serum glucose level. c) Avoid caffeine or other stimulants, such as decongestants. d) Monitor blood counts and liver function tests.

Answer 141

a) Do not administer if respirations are less than 12 per minute. Explanation: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 per minute. The nurse should instruct a patient who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose level when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

Question 142

A patient with type 1 diabetes complains about waking up in the middle of the night nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood sugar readings have been 110 to 140 mg/dL; the patient admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse will plan to instruct the patient to do which of the following? a) Check blood glucose at 3:00 in the morning. b) Skip the evening NPH insulin dose on days when exercising and skipping meals. c) Administer an increased dose of neutral protamine Hagedorn (NPH) insulin in the evening. d) Eat a complex carbohydrate snack in the evening before bed.

Answer 142

a) Check blood glucose at 3:00 in the morning. Explanation: In the Somogyi effect, the patient has normal or elevated blood glucose at bedtime, a decrease at 2 to 3 am to hypoglycemic levels, and a subsequent increase caused by the production of counterregulatory hormones. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia.

Question 143

Which statement made by the patient indicates a need for further teaching on sleep hygiene? 1. “I’ m going to do my exercises before I eat dinner.” 2. “I’ll have a glass of wine at bedtime to relax.” 3. “I set my alarm to get up at the same time every morning.” 4. “I moved my computer to the den to do my work.”

Answer 143

“I’ll have a glass of wine at bedtime to relax.” Drinking alcohol before bed in an effort to relax indicates a need for further teaching. Alcohol should be avoided before bed because it speeds onset of sleep, reduces REM sleep, awakens the person during the night, and causes difficulty returning to sleep.

Question 144

Celiac sprue is an example of which category of malabsorption? a) Infectious diseases causing generalized malabsorption b) Mucosal disorders causing generalized malabsorption c) Luminal problems causing malabsorption d) Postoperative malabsorption

Answer 144

b) Mucosal disorders causing generalized malabsorption ## Footnote Explanation: In addition to celiac sprue, regional enteritis and radiation enteritis are examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small-bowel bacterial overgrowth, tropical sprue, and Whipple’s disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection can result in development of malabsorption syndromes.

Question 146

The nurse planning care for a male patient with overflow and stress incontinence includes preparation for which of the following? a) Intravenous urogram b) Transrectal resection c) MRI d) CT scan

Answer 146

b)Transrectal resection Explanation: A transrectal resection is the procedure of choice for men with overflow and stress incontinence.

Question 147

The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they say which of the following? a) “Many oral cancers produce no symptoms in the early stages.” b) “A typical lesion is soft and craterlike.” c) “Blood testing is used to diagnose oral cancer.” d) “Most oral cancers are painful at the outset.”

Answer 147

a) “Many oral cancers produce no symptoms in the early stages.” ## Footnote Explanation: The most frequent symptom of oral cancer is a painless sore that does not heal. The patient may complain of tenderness, and difficulty with chewing, swallowing, or speaking as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.

Question 148

A patient is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the patient’s symptoms to be that of diabetic ketoacidosis (DKA). Which of the following actions will help the nurse confirm the diagnosis? a) Assessing for excessive sweating b) Assessing the patient’s breath odor c) Assessing the patient’s ability to take a deep breath d) Assessing the patient’s ability to move all extremities

Answer 148

b) Assessing the patient’s breath odor Explanation: DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated. The breath has a characteristic fruity odor due to the presence of ketoacids. Checking the patient’s breath will help the nurse confirm the diagnosis.

Question 148

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient’s level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

Answer 148

The amount of daily acetaminophen The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control.

Question 149

Which of the following actions when preformed by the nurse indicates understanding of one basic principle of providing effective pain management? a) Wakening a new postoperative patient to take his or her pain medication b) Administering a dose of an analgesic agent via patient-controlled analgesia (PCA) during rounds c) Administering pain medications on a PRN (as needed) basis d) Continuing to provide around the clock pain medications 72 hours following a surgical

Answer 149

a) Wakening a new postoperative patient to take his or her pain medication Explanation: Awakening postoperative patients with moderate-to-severe pain to take pain medication is especially important during the first 24 to 48 hours after surgery to keep pain under control. The PCA is an interactive method of pain management that allows patients to treat their pain by self-administering doses of analgesic agents and should not be used by the nurse.

Question 150

The patient states that she “loses urine” every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: 1. “I will perform my Kegel exercises every day.” 2. “I joined weight watchers.” 3. “I drink two glasses of wine with dinner.” 4. “I have tried urinating every 3 hours.”

Answer 150

“I drink two glasses of wine with dinner.” Alcohol is a bladder irritant. It increases urine production and causes uncontrolled bladder contractions.

Question 151

The nurse is assessing a patient for signs and symptoms of stress. Which of the following should the nurse include in this assessment? Select all that apply. a) Energy level b) Substance use/abuse c) Menstrual cycle d) Oral mucosa

Answer 151

a) Energy level, b) Substance use/abuse, c) Menstrual cycle, d) Oral mucosa ## Footnote Explanation: Symptoms of stress include decreased energy level and fatigue, dry mouth, changes in the menstrual cycle, and substance use/abuse as well as gastrointestinal, genitourinary, cardiovascular, neuromuscular, and psychosocial changes, including feeling weak or dizzy, hyperactivity, difficulty sleeping, palpitations and anxiety, increased urination, nausea, and decreased appetite.

Question 152

For a patient with salivary calculi, which of the following procedures uses shock waves to disintegrate the stone? a) Lithotripsy b) Radiation c) Chemotherapy d) Biopsy

Answer 152

a) Lithotripsy ## Footnote Explanation: Lithotripsy uses shock waves to disintegrate the stone. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.

Question 154

The nurse needs to carefully monitor a patient with traumatic injuries. Which of the following actions by the nurse demonstrates understanding of the most essential component of the patient’s pain assessment? a) The nurse administers pain medication based on the patient’s reported pain level. b) The nurse administers ketorolac (Toradol) on admission to the unit. c) The nurse assesses the response to medication after every meal consumed by the patient. d) The nurse validates the patient’s report of pain by assessing the patient’s blood pressure.

Answer 154

a) The nurse administers pain medication based on the patient’s reported pain level. Explanation: Patients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated BP or heart rate does not mean the absence of pain. The ability of an individual to give a report, in the case of pain—especially its intensity—is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the patient. Pain medication should not routinely be administered to a patient on admission to the unit.

Question 155

Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure? a) Reflex b) Urge c) Overflow d) Stress

Answer 155

d)Stress Explanation: Stress incontinence may occur with sneezing and coughing. Overflow incontinence refers to the involuntary loss of urine associated with overdistention of the bladder. Urge incontinence refers to involuntary loss of urine associated with urgency. Reflex incontinence refers to the involuntary loss of urine due to involuntary urethral relaxation in the absence of normal sensations.

Question 157

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, “The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months.” The patient is using the defense mechanism: 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement.

Answer 157

Denial. Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient’s statements reflect denial about poorly controlled blood sugars.

Question 159

When a person thinks about whether it is possible to do something about a situation, he or she is exhibiting what type of appraisal? a) Hardiness b) Primary c) Reappraisal d) Secondary

Answer 159

d) Secondary ## Footnote Explanation: Secondary appraisal is an evaluation of what might and can be done about a situation. Primary appraisal results in a situation being identified as either nonstressful or stressful. Reappraisal is a change of opinion based on new information. Hardiness is the name given to a general quality that comes from having rich, varied, and rewarding experiences.

Question 160

The nurse understands that which of the following is true about tolerance and addiction? a) Addiction to opioids commonly develops. b) Tolerance to opioids is uncommon. c) The nurse must be primarily concerned about development of addiction by the patient in pain. d) Although patients may need increasing levels of opioids, they are not addicted.

Answer 160

d) Although patients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare, and should never be the primary concern for a patient in pain.

Question 161

Which of the following is the term for a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? a) Chancre b) Actinic cheilitis c) Leukoplakia d) Lichen planus

Answer 161

a) Chancre ## Footnote Explanation: A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually in the buccal mucosa.

Question 163

The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening? a) History of skin cancer b) Low-fat, low-protein, high-fiber diet c) Being younger than 40 years of age d) Familial polyposis

Answer 163

d) Familial polyposis ## Footnote Explanation: Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Being older than age 40 is a risk factor for colorectal cancer. A high-fat, high-protein, low-fiber diet is a risk factor for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.

Question 164

The nurse is developing a plan of care for a patient experiencing narcolepsy. Which intervention is appropriate to include on the plan? 1. Instruct the patient to increase carbohydrates in the diet 2. Have patient limit fluid intake 2 hours before bedtime 3. Preserve energy by limiting exercise to morning hours 4. Encourage patient to take one or two 20-minute naps during the day

Answer 164

Encourage patient to take one or two 20-minute naps during the day A person with narcolepsy has the problem of falling asleep uncontrollably at inappropriate times. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timing daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol; heavy meals; exhausting activities; long-distance driving; and long periods of sitting in hot, stuffy rooms).

Question 165

When doing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as \_\_\_\_\_\_\_\_\_\_\_\_.

Answer 165

Posttraumatic stress disorder (PTSD)

Question 166

Which of the following is one of the primary symptoms of irritable bowel syndrome (IBS)? a) Bloating b) Diarrhea c) Pain d) Abdominal distention

Answer 166

b) Diarrhea ## Footnote Explanation: The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern

Question 167

Which of the following statements is true regarding gestational diabetes? a) It occurs in most pregnancies. b) A glucose challenge test should be performed between 24 and 28 weeks. c) Its onset is usually in the first trimester. d) There is a low risk for perinatal complications.

Answer 167

b) A glucose challenge test should be performed between 24 and 28 weeks. Explanation: A glucose challenge test should be performed between 24 and 48 weeks. It occurs in 2% to 5% of all pregnancies. Onset is usually in the second or third trimester. There is an above-normal risk for perinatal complications.

Question 168

The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: 1400. 1600 1700. 2300.

Answer 168

1700. The patient may experience urinary retention after removal of the catheter. If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley.

Question 169

The nurse is caring for patient scheduled to undergo radical neck dissection. During preoperative teaching, the nurse includes that which of the following as associated complications? a) Clavical fracture b) Neck distension c) Shoulder drop d) Venous engorgement

Answer 169

c) Shoulder drop ## Footnote Explanation: The nurse should include shoulder drop as an associated complication of radical neck dissection. Another associated complication includes poor cosmesis, which is a visible depression in the neck. Clavicle fracture, venous engorgement, and neck distension are not complications associated with radical neck dissection.

Question 170

The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: 1. Use the double-voiding technique. 2. Perform Kegel exercises. 3. Use Credé’s method. 4. Keep a voiding diary.

Answer 170

Use Credé’s method. With this method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter.

Question 171

Which of the following categories of laxatives draws water into the intestines by osmosis? a) Stimulants (Dulcolax) b) Saline agents (Milk of Magnesia) c) Fecal softeners (Colace) d) Bulk-forming agents (Metamucil

Answer 171

b) Saline agents (Milk of Magnesia) ## Footnote Explanation: Saline agents use osmosis to stimulate peristalsis and act within 2 hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners hydrate the stool by surfactant action on the colonic epithelium, resulting in mixing of aqueous and fatty substances.

Question 172

Which of the following is an age-related change that may affect diabetes and its management? a) Increased bowel motility b) Increased thirst c) Hypotension d) Decreased renal function

Answer 172

d) Decreased renal function Explanation: Decreased renal function affects the management of diabetes. With decreasing renal function, it takes longer for oral hypoglycemic agents to be excreted by the kidneys and changes in insulin clearance occur with decreased renal function. Other age-related changes that may affect diabetes and its management include hypertension, decreased bowel motility, and decreased thirst.

Question 173

A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse’s first assessment for stress the nurse says: 1. “Tell me who I can call to help you.” 2. “Tell me what bothers you the most about this experience.” 3. “I’ll contact someone who can help get you temporary housing.” 4. “I’ll sit with you until other family members can come help you get settled.”

Answer 173

“Tell me what bothers you the most about this experience.” The patients’ appraisal of the crisis is the most important area to address first.

Question 174

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse’s first action is to: 1. Call the patient’s health care provider. 2. Administer pain medication as ordered. 3. Check the patient’s vital signs. 4. Assess the characteristics of the pain.

Answer 174

Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is *not* simply a number.

Question 175

A 75-year-old patient had surgery for her hip fracture yesterday. She is under stress due to the pain, the medications, sleep deprivation, and hospital surroundings. Which of the following nursing interventions to treat the patient’s pain when ordered by the doctor should the nurse question? a) Advil for pain management. b) Morphine rather than Advil for pain management c) Acetaminophen for pain management d) Use of transelectrical nerve stimulator (TENS)

Answer 175

a) Advil for pain management. Explanation: NSAIDs, such as Advil, increase the risk of GI toxicity in individuals older than 60 years and should be assessed further prior to administration. There are many risk factors for opioid-induced respiratory depression in individuals older than 65 years; a thorough respiratory assessment is indicated. Acetaminophen should be used for mild pain. Nonpharmacologic methods of pain management, such as TENS, are acceptable in this situation. Society has proposed that opioids are a safer choice than NSAIDs in many older adults because of the increased risk for NSAID-induced GI adverse effects in that population.

Question 177

To minimize the patient experiencing nocturia, the nurse would teach him or her to: 1. Perform perineal hygiene after urinating. 2. Set up a toileting schedule. 3. Double void. 4. Limit fluids before bedtime.

Answer 177

Limit fluids before bedtime. With nocturia the patient has to get up during the night to urinate. Limiting fluids 2 hours before bedtime minimizes nocturia.

Question 179

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis.

Answer 179

An adventitious crisis. An adventitious crisis is a type of crisis resulting from a natural disaster such as a tsunami.

Question 180

The nurse is caring for an older adult who complains of xerostomia. The nurse evaluates for use of which of the following medications? a) Antibiotics b) Diuretics c) Antiemetics d) Steroids

Answer 180

b) Diuretics ## Footnote Explanation: Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the patient’s risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.

Question 181

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider’s order reads as follows: “Vicodin 1 tab, per tube, q4 hours, prn.” Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the ordered changed to ATC for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the Vicodin when the patient shows nonverbal symptoms of pain.

Answer 181

Request to have the ordered changed to ATC for the first 48 hours. The American Pain Society (2003) states that, if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.

Question 182

The nurse is providing health teaching for a patient using herbal compounds such as melatonin for sleep. Which points need to be included? (Select all that apply.) 1. Can cause urinary retention 2. Should not be used indefinitely 3. May cause diarrhea and anxiety 4. May interfere with prescribed medications 5. Can lead to further sleep problems over time 6. Are not regulated by the U.S. Food and Drug Administration (FDA)

Answer 182

Should not be used indefinitely May interfere with prescribed medications Are not regulated by the U.S. Food and Drug Administration (FDA)

Question 184

The nurse is caring for a patient with diabetes who has an infection. The nurse creates a plan of care for the patient based on a knowledge of the hypothalamic-pituitary response to stress by including which of the following nursing interventions in the plan of care? a) Assessment for hyperglycemia b) Restriction of dietary protein c) Increasing insulin dosage d) Measurement of intake/output

Answer 184

a) Assessment for hyperglycemia ## Footnote Explanation: The hypothalamic-pituitary response to stress includes stimulation of the adrenal cortex to produce glucocorticoids that inhibits glucose uptake. This increases the patient with diabetes need for insulin and the need for the nurse to assess for hyperglycemia. Although the patient’s insulin dosage will most likely need to be increased, this is not a nursing action and requires a physician’s order.Restriction of dietary protein is contraindicated because the hypothalamic-pituitary response includes catabolism of body protein. Measurement of intake/output is not indicated in this case.

Question 185

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which of the following factors as a cause of type 1 diabetes? a) Rare ketosis b) Obesity c) Presence of autoantibodies against islet cells d) Altered glucose metabolism

Answer 185

c) Presence of autoantibodies against islet cells Explanation: There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

Question 186

The nurse needs to carefully monitor a patient with traumatic injuries. Which of the following actions by the nurse demonstrates understanding of the most essential component of the patient’s pain assessment? a) The nurse administers ketorolac (Toradol) on admission to the unit. b) The nurse administers pain medication based on the patient’s reported pain level. c) The nurse validates the patient’s report of pain by assessing the patient’s blood pressure. d) The nurse assesses the response to medication after every meal consumed by the patient.

Answer 186

b) The nurse administers pain medication based on the patient’s reported pain level. Explanation: Patients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated BP or heart rate does not mean the absence of pain. The ability of an individual to give a report, in the case of pain—especially its intensity—is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the patient. Pain medication should not routinely be administered to a patient on admission to the unit.

Question 187

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of “sick days.” The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse’s best response? a) Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood. b) When the body does not have enough insulin hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic byproducts to be released. c) Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid. d) Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy.

Answer 187

d) Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

Question 188

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? 1. Have patient follow hospital routines 2. Avoid awakening patient for nonessential tasks 3. Give prescribed sleeping medications at dinner 4. Turn television on low to late-night programming.

Answer 188

Avoid awakening patient for nonessential tasks Avoiding awakening patient for nonessential tasks promotes sleep. Cluster activities and allow the patient time to sleep. Do not perform tasks such as laboratory draws and bathing during the night unless absolutely essential. Patients should try to follow home routines related to sleep habits. The other tasks do not promote sleep.

Question 190

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? (Select all that apply.) 1. Do not study in your bed. 2. Go to sleep each night whenever you feel tired. 3. Turn off your cell phone at bedtime. 4. Avoid drinking coffee or soda before bedtime. 5. Turn on the television to help you fall asleep.

Answer 190

Do not study in your bed. Turn off your cell phone at bedtime. Avoid drinking coffee or soda before bedtime.

Question 191

The nurse is caring for a patient receiving chemotherapy. For which of the following mouth conditions associated with HIV infection should the nurse assess? Select all that apply. a) Candidiasis b) Kaposi’s sarcoma c) Stomatitis d) Krythoplakia

Answer 191

b) Kaposi’s sarcoma, c) Stomatitis ## Footnote Explanation: Kaposi's sarcoma appears first on the oral mucosa as a red, purple, or blue lesion that is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy, as well as HIV infection. Krythoplakia is caused by a nonspecific inflammation, and candidiasis is caused by fungus.

Question 192

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient’ s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: 1. Discontinue all ordered opioids 2. Close the room door to allow the patient to recover 3. Administer the remaining naloxone over 4 minutes 4. Assess patient’s vital signs every 15 minutes for 2 hours

Answer 192

Assess patient’s vital signs every 15 minutes for 2 hours Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory depression may return.

Question 193

The nurse understands the definition of pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Which of the following comments when made by the patient confirms patient understanding of the fundamental concepts of pain? Select all that apply. a) “I will depend on you and your experience to treat my pain, as you feel appropriate.” b) “I feel good in knowing that my doctor will determine when and how I get pain medication.” c) “I would love to go to church, but my back pain is too uncomfortable to make it through the service.” d) “I am tired of living with this nagging pain; I’m not sure how much longer I can go on.” e) “I used to walk every day for exercise; pain in my knee made me stop walking.”

Answer 193

c) “I would love to go to church, but my back pain is too uncomfortable to make it through the service.” d) “I am tired of living with this nagging pain; I’m not sure how much longer I can go on.” e) “I used to walk every day for exercise; pain in my knee made me stop walking.” Explanation: A fundamental concept of pain is that pain is a complex phenomenon that can affect a person’s psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The patient’s report is the most reliable indicator of pain. The patient works with the nurse and doctor to establish a pain management regimen.

Question 194

The nurse is conducting a community health education program on obesity. The nurse includes which of the following diseases/disorders in the program? a) Obstructive sleep apnea b) Oral cancer c) Rheumatoid arthritis d) Chronic obstructive pulmonary disease

Answer 194

a) Obstructive sleep apnea ## Footnote Explanation: The nurse includes that obstructive sleep apnea is a disease/disorder associated with obesity as well as asthma; breast, endometrial, prostate, renal, colon, and gallbladder cancer; osteoarthritis, coronary artery disease, cholecystitis, cholelithiasis, chronic back pain, diabetes, hypertension, coronary artery disease, heart failure, and pulmonary embolism.

Question 195

he nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation? a) Apply barrier powder b) Dry skin thoroughly after washing c) Dust with nystatin powder d) Apply Kenalog spray

Answer 195

b) Dry skin thoroughly after washing ## Footnote Explanation: The nurse should teach the patient without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, Kenalog spray, and nystatin powder are used when there is peristomal skin irritation and/or fungal infection.

Question 196

The nurse is conducting a health risk appraisal. The nurse should include which of the following? Select all that apply. a) Blood pressure b) Recreational activities c) Driving habits d) Educational level

Answer 196

a) Blood pressure , b) Recreational activities, c) Driving habits ## Footnote Explanation: When conducting a health risk appraisal, the nurse should include personal and family history of disease, lifestyle choices, and physical measurements, including recreational activities, driving habits, and blood pressure. Educational level is not included in a health risk appraisal.

Question 197

Which of the following factors is the focus of nutrition intervention for patients with type 2 diabetes? a) Blood glucose level b) Carbohydrate intake c) Weight loss d) Protein metabolism

Answer 197

c) Weight loss Explanation: In most instances, people with type 2 diabetes require weight reduction; therefore, weight loss is the focus of nutrition intervention for patients with type 2 diabetes. A low-calorie diet may reduce clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action.

Question 198

The nurse is teaching a patient with recurrent urinary tract infections (UTIs) ways to decrease her risk for additional UTIs. The nurse includes which of the following? a) Void immediately after sexual intercourse. b) Void every 5 hours during the day. c) Increase intake of coffee, tea, and colas. d) Take tub baths instead of showers.

Answer 198

a)Void immediately after sexual intercourse. Explanation: The nurse should include that the patient should void immediately after sexual intercourse to flush the urethra, expelling contaminants. Showers are encouraged rather than tub baths because bacteria in the bath water may enter the urethra. Coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants should be avoided. The patient should be encouraged to void every 2 to 3 hours during the day and completely empty the bladder.

Question 199

The nurse is evaluating a patient’s social support network. The nurse evaluates that the network will assist the patient in coping with stress when which of the following is noted? a) Son does not acknowledge his mother’s diagnosis b) Daughter helps mother with laundry c) Patient avoids situations exposing her to new people d) Patient’s friends ask her for advice

Answer 199

b) Daughter helps mother with laundry ## Footnote Explanation: Social networks assist in the management of stress when they provide material aid and tangible services, such as a daughter helping her mother with the laundry. Additionally, networks should provide a positive social identity and emotional support as well as access to information and new social contacts/social roles.

Question 200

Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland? a) Sialolithiasis b) Parotitis c) Stomatitis d) Sialadenitis

Answer 200

a) Sialolithiasis ## Footnote Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa

Question 201

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA prevents overdoses from occurring. 4. Notify the nurse when the button is pushed.

Answer 201

Only the patient should push the button. Patient preparation and teaching are critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to “push the button” for the patient.

Question 202

The nurse is developing a plan of care to assist a patient in coping with a right leg-below-the-knee amputation (BKA). Which of the following interventions should the nurse include? a) Establishment of nurse-determined goals b) Discouragement of complementary medicine c) Subjective appraisal of event by patient d) Patient’s verbalization of feelings of loss

Answer 202

d) Patient’s verbalization of feelings of loss ## Footnote Explanation: Nursing interventions to enhance patient coping with stressful events include allowing the patient to verbalize feeling of loss, such as those associated with the loss of a lower extremity. The nurse should also encourage objective appraisal of the event by the patient, and assist the patient in establishing mutual patient–nursing goals. If the patient desires, the nurse should encourage the use of complementary medicine, such as meditation.

Question 203

he nurse is irrigating a patient’s colostomy when the patient begins to complain of cramping. What is the appropriate action by the nurse? a) Change irrigation fluid to normal saline. b) Clamp the tubing and allow patient to rest. c) Increase the rate of administration. d) Discontinue the irrigation immediately.

Answer 203

b) Clamp the tubing and allow patient to rest. ## Footnote Explanation: The nurse should clamp the tubing and allow the patient to rest when the patient begins to complain of cramping during colostomy irrigation. Once the cramping has stopped, the nurse can resume the irrigation.

Question 204

Which of the following route of medication administration should the nurse consider first in an NPO (nothing by mouth) postoperative patient following IV removal? a) Intrathecal b) Subcutaneous c) Rectal d) Topical

Answer 204

c) Rectal Explanation: The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option. The rectum allows passive diffusion of medications and absorption into the systemic circulation. Topical agents produce effects in the tissues immediately under the site of application. Intrathecal catheters for acute pain management are used most often for providing anesthesia or a single bolus dose of an analgesic agent. The subcutaneous route of administration is not recommended in this situation.

Question 205

he nurse is conducting discharge teaching for a patient with diverticulosis. Which of the following should the nurse include in the teaching? a) Avoid unprocessed bran. b) Drink 8 to 10 glasses of fluid daily. c) Use laxatives weekly. d) Avoid daily exercise.

Answer 205

b) Drink 8 to 10 glasses of fluid daily. ## Footnote Explanation: The nurse should instruct a patient with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The patient should include unprocessed bran in the diet because it adds bulk and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, the patient should exercise regularly if his or her current lifestyle is somewhat inactive