Nc 5

Front 1

Setting limits with a patient who is manipulative benefits the patient in which way? The patient is able to

Back 1

gain self-empowerment in relationships with others.Setting limits helps the patient gain self-empowerment in relationships with others. The patient will understand of how the manipulative behavior is based on immediate gratification and the associated disregard for the rights of others.

Front 2

Which symptom is associated with post-traumatic stress disorder?

Back 2

Persistent feelings of detachment from others is a symptom of posttraumatic stress disorder (PTSD). PTSD can occur following the experience or witnessing of a life-threatening event. The patient relives the event through flashbacks, dreams, and intrusive recollections.

Front 3

Which behavior by a high school student is a sign that the student may be potentially suicidal?

Back 3

The student misses classes and withdraws from the gymnastics teamRationale for Choice 3: These are examples of social isolation and loss of interest in usual activities. which indicate a high risk for suicide.

Front 4

A patient admitted with bipolar disorder jumps up during a group meeting and starts to sing and dance. What is the most appropriate nursing intervention?

Back 4

Take the patient to a quieter location.Rationale for Choice 2: The patient requires assistance to provide external controls on destructive behaviors and to maintain safety. The most appropriate action is to take the patient to a quieter location.

Front 5

A child who has autistic disorder is likely to display symptoms of the illness by which age?

Back 5

4 monthsRationale for Choice 1: Although it is difficult to give a definitive diagnosis of autism before age three years, the child may show symptoms of autism such as lack of social responsiveness by age four months.

Front 6

The nurse establishes a nursing diagnosis of ineffective denial related to a fear of losing control over eating for a patient with anorexia nervosa. Which is an appropriate patient outcome? The patient will

Back 6

verbalize understanding that eating behaviors are maladaptive.Rationale for Choice 3: Verbalizing this understanding is directly related to the fear of losing control over eating which is an ineffective denial mechanism.

Front 7

It is most important for the nurse to evaluate a patient who is manic in which area?

Back 7

nutritional statusRationale for Choice 3: It is most important to evaluate nutritional status. If the patient is dehydrated or malnourished along with having faulty judgment, the patient will be at risk for injury.

Front 8

The nurse is evaluating care for an outpatient who is receiving lithium carbonate (Lithane). Which statement reflects the need for further instruction regarding the medication?

Back 8

"I will adhere to a low-salt diet."Rationale for Choice 2: The patient should not follow a low-salt diet. A low sodium intake causes a relative increase in lithium retention which can lead to toxicity. Further instruction is necessary.

Front 9

The nurse is closely attending a patient who has been expressing suicidal ideation. What is the nurse's best response when the patient asks why she is being followed around?

Back 9

"You've been talking of harming yourself, and I don't want anything to happen to you."Rationale for Choice 4: This response is an example of the nurse being direct and specific to the issue of suicide. The nurse also uses the patient's ambivalence as a tool. It is important to deal directly with the patient's suicidal ideation.

Front 10

Which behavior may indicate impaired impulse control?

Back 10

An adult accelerates rapidly when the traffic signal turns yellow.

Front 11

The nurse would expect to see improvement in the manic symptoms of a patient with bipolar disorder when carbamazepine (Tegretol) is at which serum level?

Back 11

6-8 mg/LRationale for Choice 4: Carbamazepine (Tegretol) dosage should be maintained at a serum level of 6 to 8 mg/L.

Front 12

What symptoms would the nurse expect to find in a patient with neuroleptic malignant syndrome?

Back 12

high fever and muscle rigidityRationale for Choice 2: High fever and muscle rigidity are symptoms of neuroleptic malignant syndrome which is a rare and potentially fatal side effect of antipsychotic medication.

Front 13

A patient has been taking lithium for 2 weeks for the manic phase of bipolar disorder. When the patient's lithium level reaches 1.2, which patient behavior can the nurse expect?

Back 13

modulation of mood and ability to solve problemsRationale for Choice 4: A lithium level of 1.2 mEq/L is within the maintenance blood level range of 0.4 - 1.3 mEq/L. Therapeutic outcomes would be a modulation of mood and ability to solve problems.

Front 14

Which result should the nurse expect when using reminiscence therapy with patients who are older adults?

Back 14

increased self-esteemRationale for Choice 3: Increased self-esteem is an expected outcome of reminiscing therapy.

Front 15

Which community development indicates the effectiveness of a nurse's teaching program regarding the needs of persons with irreversible dementia, such as Alzheimer's disease?

Back 15

The local church develops a day treatment center.Rationale for Choice 3: *Providing a service specifically geared toward older adults who need a place to be during the day is an effective response to the nurse's teaching.

Front 16

Which characteristic of early-stage Alzheimer's dementia should the nurse consider in conducting a cognitive assessment?

Back 16

is aware of their lost abilities.Rationale for Choice 1: *Awareness of the loss of abilities is characteristic of early-stage Alzheimer's dementia, where the patient is very aware that something is wrong.

Front 17

What is the rationale for using propranolol hydrochloride (Inderal) in the management of patients with cirrhosis of the liver?

Back 17

Prevent bleeding from esophageal varices.Rationale for Choice 2: Varices are varicosities that develop from elevated pressure transmitted to all of the veins that drain into the portal system. Inderal will reduce the portal pressure by its beta-adrenergic blocking action.

Front 18

Which route should be used to give vitamins A, D, and E to a patient with hepatic cirrhosis who is experiencing steatorrhea?

Back 18

total parenteral nutritionRationale for Choice 2: Because a patient with steatorrhea is experiencing malabsorption of fats, these fat-soluble vitamins should be administered as part of TPN.

Front 19

Which co-existing condition should the nurse recognize as a problem in the patient with acute pancreatitis?

Back 19

pleural effusionRationale for Choice 3: Pleural effusion is a coexisting condition that a nurse should recognize as a problem in the patient with acute pancreatitis.

Front 20

Which type of medication should the nurse question in the order for a patient with end-stage hepatic dysfunction?

Back 20

Rationale for Choice 3: Sedatives precipitate hepatic encephalopathy and should be used sparingly.

Front 21

To improve the nutritional status of a patient with Graves' disease, the nurse should include which action in the plan of care?

Back 21

Provide the patient with a quiet atmosphere during meals.Rationale for Choice 3: Providing a quiet atmosphere may aid digestion. A patient with hyperthyroidism is often irritable and has difficulty coping with stress.

Front 22

A nursing assistant tells the nurse that a patient with diabetes insipidus is asking to have the water pitcher refilled several times a day. Which would be the best action by the nurse?

Back 22

Instruct the assistant to limit the patient's fluid intake.Rationale for Choice 3: Fluids should be limited to an amount equivalent to output. This will still result in quite a lot of fluid intake.

Front 23

A patient with hyperparathryoidism is encouraged to remain as physically active as possible because decreased mobility may lead to which problem?

Back 23

renal calculiRationale for Choice 1: Kidney involvement is a common threat in hyperparathyroidism. This coupled with the excess calcium secretion associated with immobility places the patient at risk for renal calculi.

Front 24

A patient with hypothyroidism who is taking hormone replacement therapy may be at risk for the development of which health problem?

Back 24

hyperglycemiaRationale for Choice 1: Thyroid hormones increase blood glucose levels.

Front 25

Which finding should the nurse expect in a patient with hyperparathyroidism?

Back 25

fatigueRationale for Choice 2: Fatigue is a common finding in patients with hyperparathyroidism, because calcium is concentrating in the bloodstream.

Front 26

In caring for a patient with edema associated with nephrotic syndrome, the nurse must carefully monitor the use of diuretics for which reason?

Back 26

Reduced plasma volume may precipitate acute renal failure.Rationale for Choice 3: The volume of extracellular fluid removed by use of diuretics can bring on hypovolemia (shock), leading to acute renal failure.

Front 27

What is the primary focus of cognitive therapy?

Back 27

current problemsRationale for Choice 4: Cognitive therapy is an active, directive, time-limited, structured approach that addresses current problems.

Front 28

Which finding should the nurse expect when taking a history from a patient with a conversion disorder?

Back 28

actual change or loss of body functionRationale for Choice 4: Conversion disorder involves unexplained symptoms or defects affecting voluntary motor or sensory function suggesting a neurological or other general medical condition.

Front 29

Which disorder is associated with an excess of the neurotransmitter dopamine?

Back 29

schizophreniaRationale for Choice 4: An excess of dopamine can exacerbate the symptoms of schizophrenia in psychotic patients.

Front 30

A college student who is away from home for the first time has trouble sleeping, cannot concentrate on her studies, and calls home several times a day to ask for her mother's advice. What is the student most likely experiencing?

Back 30

Rationale for Choice 1: The student's behavior is not a normal reaction to being away from home at this age and indicates a developmental crisis. This is assessed using developmental assessment strategies that compare information about the student's current maturational level with her chronological age.

Front 31

Which client would benefit most from cognitive therapy?

Back 31

an adolescent who has chronic painRationale for Choice 1: Cognitive therapy is an active, directive, time-limited, structured approach that addresses current problems such as chronic pain.

Front 32

According to psychodynamic theory, an individual who places a high value on self-control is most likely to experience which initial response when that control is threatened?

Back 32

anxietyRationale for Choice 1: A person who values self-control highly will react to stress as a threat to self. The initial stress reaction in most cases is anxiety.

Front 33

A patient who was initially admitted for depression now announces that she feels great, races energetically around the unit, describes her cure for cancer, and rapidly changes topics of conversation. These presenting features and the patient's past history of depression should lead the nurse to suspect that the patient has which condition?

Back 33

bipolar disorderRationale for Choice 3: These signs indicate an acute phase of the manic stage of bipolar disorder.

Front 34

Why is it essential for the nurse to be aware of the thoughts of a patient who has delusions of being an important political leader?

Back 34

to identify factors that may influence the patient's behaviorRationale for Choice 1: The nurse needs to identify the political leader's characteristics, actions, and circumstances so the nurse can understand how these factors influence the patient's behavior.

Front 35

What nursing diagnosis takes priority for a patient with major depression who is being admitted to an inpatient treatment center?

Back 35

risk for self-directed violence related to angerRationale for Choice 1: A risk for self-directed violence would take immediate priority.

Front 36

A patient is receiving a tricyclic antidepressant medication. The nurse should observe this patient for which side effect?

Back 36

orthostatic hypotensionRationale for Choice 2: Orthostatic hypotension is a result of the alpha-adrenergic blockade of the tricyclic antidepressant.

Front 37

A patient who has anorexia nervosa is likely to experience difficulty with which developmental achievement?

Back 37

establishing individual autonomyRationale for Choice 2: The patient with anorexia nervosa has difficulty with self-image and with trusting themselves.

Front 38

A patient taking lithium carbonate complains of fine hand tremors and slight thirst. The nurse would expect the patient's blood level of lithium to be at which value?

Back 38

0.4-1.0 mEq/LRationale for Choice 1: These signs indicate a therapeutic level of lithium.

Front 39

Which statement most accurately describes one of Harry Stack Sullivan's concepts related to mental health and illness?

Back 39

Anxiety occurs when one is unsuccessful at satisfying needs or achieving interpersonal security.Rationale for Choice 4: According to Sullivan's interpersonal theory, anxiety comes from tension that arises from social insecurity or blocks to satisfaction. Sullivan defines needs as the need for satisfaction.

Front 40

Which is an appropriate expected outcome for a five-year-old child who is autistic and has a nursing diagnosis of social isolation? The child will

Back 40

make attempts to offer toys to peers.Rationale for Choice 4: This is an appropriate behavioral outcome for this child.

Front 41

The nurse suggests that a patient use all five senses to mentally create a relaxing environment to help the patient manage the physiological symptoms of stress. Which term describes the nursing measure used in this situation?

Back 41

guided imageryRationale for Choice 3: The nurse is using guided imagery, a process in which a person is left to envision images that that are calming and health enhancing.

Front 42

Which behavior is characteristic of all types of personality disorders?

Back 42

inflexible response to stressRationale for Choice 2: Inflexible response to stress is a behavior common to all conditions in all three clusters of personality disorders.

Front 43

Which laboratory finding supports the nursing diagnosis of fluid volume deficit in a patient with diabetes insipidus?

Back 43

increased serum sodiumRationale for Choice 4: Because a patient with diabetes insipidus is not excreting sodium, the substance builds up in the bloodstream, producing increase serum sodium levels.

Front 44

Which nursing assessment is a priority for a patient with pheochromocytoma?

Back 44

vital signsRationale for Choice 2: Pheochromocytoma is characterized by headache, diaphoresis, and palpitations. These three classic symptoms are often accompanied by high blood pressure and other cardiovascular problems. Assessing vital signs should be a priority during the assessment phase.

Front 45

Which vital sign is monitored closely in a patient who is receiving epoetin alfa (Epogen) for the treatment of anemia associated with chronic renal failure?

Back 45

blood pressureRationale for Choice 4: Epogen may cause hypertension, especially early in the treatment program.

Front 46

A patient with renal failure is given aluminum hydroxide gel (Amphojel) after meals and at bedtime. The nurse would anticipate which effect from this therapy? Management of

Back 46

hyperphosphatemiaRationale for Choice 1: Amphojel is used to manage excess phosphorus in a patient with renal failure.

Front 47

Which action is most appropriate for a nurse when discussing physical and psychological changes with a patient who has undergone a kidney transplant after years of dialysis?

Back 47

Rationale for Choice 4: The National Association of Kidney Patients is an excellent single point of contact to identify support for this patient.

Front 48

Oversecretion of growth hormone during childhood normally results in which condition?

Back 48

Rationale for Choice 3: Gigantism is the result of oversecretion of growth hormone during childhood.

Front 49

The nurse is preparing a room for a patient who is undergoing a partial thyroidectomy. Which equipment should be available in this patient's room?

Back 49

tracheostomy tray, suction apparatus, and IV calcium gluconateRationale for Choice 1: A patient having a partial thyroidectomy is at risk for a breathing emergency because of swelling of the throat, hematoma, or nerve injury. A tracheostomy set should be available at all times in the postoperative period.

Front 50

A nursing assistant reports that a patient with renal failure has gained 5 pounds since yesterday. Which is the most appropriate action by the nurse?

Back 50

Assess the patient's breath sounds.Rationale for Choice 1: This finding indicates a dangerous build-up of fluids that may lead to heart failure or pulmonary edema.

Front 51

Which statement best indicates that levothyroxine sodium (Synthroid) therapy for a patient with hypothyroidism has been effective?

Back 51

"I felt warm, so I opened the window."Rationale for Choice 2: A patient with hypothyroidism usually feels cold. This statement indicates an improvement that can probably be attributed to Synthroid therapy.

Front 52

Which statement by the patient with polycystic kidney disease indicates a need for further teaching?

Back 52

"If I follow this aggressive treatment plan, I might be cured of the disease."Rationale for Choice 3: Polycystic kidney disease is a chronic condition with no specific treatment.

Front 53

A patient with hyperthyroidism (Graves' disease) is receiving Lugol's solution prior to a thyroidectomy. What is the desired therapeutic effect of this medication?

Back 53

to reduce the vascularity of the thyroid glandRationale for Choice 2: Iodine preparation such as Lugol's solution are administered to reduce blood loss by reducing vascularity and size of the thyroid gland.

Front 54

Why is it important to gradually introduce thyroid supplementation to an older adult patient who has hypothyroidism?

Back 54

Cardiovascular changes put older adult patients at risk for angina and myocardial infarction.Rationale for Choice 2: For older adults being treated for hypothyroidism, starting with low dosages and increasing them gradually is necessary to avoid cardiovascular and neurological side effects.

Front 55

Which is an appropriate nursing action when caring for a patient who has undergone a bilateral adrenalectomy and is receiving glucocorticoid replacement?

Back 55

Monitor serum glucose.Rationale for Choice 2: The patient taking glucocorticoids is at risk for glucose intolerance and hyperglycemia.

Front 56

A nurse is planning home care for a patient who has diabetes mellitus and is visually impaired. Which nursing action is a priority? The nurse

Back 56

assesses the patient's ability to perform a reliable capillary puncture at regular intervals.Rationale for Choice 2: The patient must be able to obtain a reliable capillary puncture at regular intervals to monitor blood sugar on an ongoing basis.

Front 57

Which medication prescribed for the patient with diabetes mellitus (type 2) acts by delaying absorption of glucose in the intestinal tract?

Back 57

acarbose (Precose)Rationale for Choice 4: Precose acts by delaying absorption of glucose in the intestinal tract.

Front 58

The nurse administers glucagon to a patient with diabetes mellitus experiencing a loss of consciousness. What is the expected therapeutic effect of this medication?

Back 58

transitory hyperglycemiaRationale for Choice 1: Glucagon is used to treat severe hypoglycemia. Glucagon accelerates the breakdown of glycogen to glucose in the liver, causing transitory hyperglycemia.

Front 59

A patient experiencing symptoms of hepatic encephalopathy is given lactulose (Cephulac) to reduce which blood component?

Back 59

ammonia Rationale for Choice 2: Lactulose acts to promote excretion of ammonia in the stool.

Front 60

A patient with pancreatic dysfunction is likely to exhibit which clinical manifestation?

Back 60

hypocalcemiaRationale for Choice 3: The patient will have hypocalcemia, elevated temp, elevated WBC, hyperglycemia

Front 61

Which patient is at risk for developing cholelithiasis? A patient with

Back 61

diabetes mellitusRationale for Choice 2: A patient with diabetes mellitus is at risk for developing cholelithiasis--
the formation of gallstones

Front 62

A patient with diabetes mellitus (type 1) is experiencing poor glycemic control. Other than poor dietary management, what is the most likely contributor to this problem?

Back 62

lipodystrophyRationale for Choice 4: Lipodystrophy is a localized reaction at the site of insulin injections. If insulin is injected into scarred areas, absorption may be delayed.

Front 63

When administering an injection to a patient with impaired liver function, the nurse should take special precautions to prevent which problem?

Back 63

bleedingRationale for Choice 1: Many patients with liver disease have clotting defects and are at risk for bleeding.

Front 64

A patient displaying the clinical manifestations of cholecystitis should be questioned about the recent ingestion of which drug?

Back 64

cholecystitis (inflammation of the gallbladder)Rationale for Choice 2: The common side effects of erythromycin are nausea or vomiting, abdominal pain, and diarrhea. Most patients with cholecystitis will present with similar symptoms.

Front 65

Which assessment finding in a patient with diabetes mellitus (type 1) is a clinical manifestation of diabetic neuropathy? The patient

Back 65

walks with an unsteady gait.Rationale for Choice 3: Patients with diabetic neuropathy may have an unsteady gait associated with a decreased sensation to light touch.

Front 66

The nurse would be alert for which assessment finding during the first 24 hours following an open cholecystectomy?

Back 66

urinary output 60 mL in 4 hoursRationale for Choice 2: A urinary output of 60 mL during the first 4 hours following an open cholecystectomy may indicate a complication. A urinary output of 30 ml/hr or greater is the acceptable outcome postoperatively.

Front 67

Which observation indicates a need for health teaching for a patient with chronic pancreatitis? The patient

Back 67

weighs himself once a week.Rationale for Choice 3: The patient should monitor weight on a daily basis.

Front 68

At which time of the day should a patient with diabetes mellitus (type 2) be instructed by the nurse to take acarbose (Precose)?

Back 68

with the first bite of each main mealRationale for Choice 2: Acarbose affects food absorption, so it must be taken immediately before a meal.

Front 69

What causes pruritus in the patient with biliary cirrhosis of the liver?

Back 69

retention of bile salts causes itchy skin (pruritus) Rationale for Choice 1: Biliary cirrhosis is the result of chronic biliary obstruction and infection in liver

Front 70

The nurse is making a home visit to assess the needs of an older adult with Alzheimer's disease. What nursing diagnosis should be the priority for this patient, based on Maslow's hierarchy of needs?

Back 70

risk for injury related to impaired judgmentRationale for Choice 4: Risk for injury is an immediate need that falls in the biological category in Maslow's hierarchy.

Front 71

Nurses often use reminiscence therapy to help older adults achieve which of Erikson's psychosocial developmental goals?

Back 71

integrityRationale for Choice 3: The crisis of integrity versus despair occurs in older adults. Reminising therapy helps older adults successfully achieve integrity.
integrity vs despair-- looking back on life with sense of fulfillment would create integrity.

Front 72

How would the nurse evaluate improvement in the self-care activities of a patient with dementia?

Back 72

Ask the nursing assistant how much of the bath was completed independently.Rationale for Choice 4: Observing the patient's change in the level of independent action is the best way to evaluate improvement in self-care activities.

Front 73

In which setting is the nurse most likely to encounter patients with delirium?

Back 73

a long-term care facility for older adults
delirium- an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech. ex. UTI and Benzos would cause delirium