Nc 5 Test 2

Front 1

Which behavioral characteristic shoudl the nurse expect in a pt who has a dx of narcissistic personality disorder?

Back 1

Lack of empathy

Front 2

Which characteristic is the most common in successful resolution of the grief response? The person who is grieving..

Back 2

Has a healthy self-esteem

Front 3

A pt with severe depression refuses to leave his room, refuses to eat, and repeats, "I'm no good." What nursing diagnosis should have first priority?

Back 3

Risk for self-directed violence

Front 4

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

Back 4

Anxiety occurs when one is unsuccessful at satisfying needs or achieving interpersonal security.
(Anxiety comes from tension that arises from social insecurity or block to satisfaction.)

Front 5

A pt taking litium carbonate complains of find hand tremors and slight thirst. The nurse would expect the pt's blood level of litium to be at which level?

Back 5

Therapeutic level 0.4 - 1.0 mEq/L

Front 6

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

Back 6

Schizophrenia

Front 7

Which finding should the nurse expect when taking a hx from a pt with conversion disorder?

Back 7

Actual change or loss of body function.
(conversion disorder involves unexplained symptoms or defects affecting voluntary motor or sensory function suggesting a neurological or other general medical condition.)

Front 8

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

Back 8

Ask the nursing asst how much of the bath was completed independently.

Front 9

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

Back 9

A developmental crisis.

Front 10

Which speech pattern is commonly seen in pts during the manic phase of bipolar disease?

Back 10

Rapid pressured speech

(other findings are elated mood, increased activity, and reduced sleep)

Front 11

Which dx criterion is specific for anorexia nervosa, but not for bulimia nervosa?

Back 11

Amenorrhea in post-menarcheal females.

Front 12

Which biological theory is exemplified when a pt with diabetes mellitus experiences secondary anxiety due to the physiological disease process?

Back 12

Hormonal

(DM is a hormonal disorder)

Front 13

What is the primary focus of cognitive therapy?

Back 13

Current problems

(It is active, directive, time-limited, strutured approach that addresses current problems.)

Front 14

The nurse removes a depressed pt from the bathroom where he was attempting to hang himself in the shower stall. Which intervention should be given priority?

Back 14

Assign one-to-one monitoring

(one to one, arms length monitoring)

Front 15

Which is the most appropriate initial nursing intervention for a pt in an acute manic phase?

Back 15

Provide a safe environment.

Front 16

Which personality disorder has as its essential features magical thinking, excessive social anxiety, and congnitive perceptual distortion?

Back 16

Schizotypal

(It is a cluster disoder (odd or eccentric) that involves a pattern of social and interpersonal deficits characterized by acute discomfort with, and reduced capacity for, close relationships)

Front 17

Which is associated with increased risk for violence among pts with schizophrenia?

Back 17

Substance abuse

(Substance abuse is assoc with homelessness, violence, and suicide in pts with schizo)

Front 18

A pt tells the nurse many details about his parents' death and funeral. He says, "I feel no loss or pain." Which defense mechanism is the pt using?

Back 18

Repression

(repression is banishing a memory)

Front 19

Which lab tests does the nurse need to monitor a pt receiving valproic acid (Valproate) therapy for bipolar disorder?

Back 19

Hepatic function

(baseline liver funct test should be monitored and reg intervals)

Front 20

What is the purpose of setting limits with a pt who displays manipulative behavior?

Back 20

To help the pt gain control and take responsibility.

Front 21

Which statement best describes phenotypes?

Back 21

Total set of genes in an individual.

(Represents the physical appearance or makeup of an individual.)

Front 22

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

Back 22

A long-term care facility for older adults

Front 23

Which observation indicates that litium carbonate (Eskalith) therapy has been effective for a pt with bipolar disorder?

Back 23

Delusions of grandeur have subsided.

Front 24

Which are the vegatative signs of depression?

Back 24

Disturbances of sleep and digestion.
(change in bowel movements, eating habits, sleep, disinterest in sex)

Front 25

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

Back 25

Anxiety

(a person who values self control highly will react to stress as a threat to self)

Front 26

Which nursing intervention is the priority for a pt who just had an electroconvulsive therapy (ECT) treatment?

Back 26

Monitor vital signs every 15 min for at least the first hour.

Front 27

Which activity can the nurse assign to the nursing asst in caring for a pt who has depression?

Back 27

Check the pt's room for potential harmful objects.

(Suicide potential is the highest assessment priority)

Front 28

Which client would benefit most from cognitive therapy?

Back 28

An adolescent who has chronic pain.

(Cognitive therapy is an active, directive, time-limted, structural approach that addresses current problems, such as chronic pain)

Front 29

A pt 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 pts past hx of depression should lead the nurse to suspect that the pt has which condition?

Back 29

Bipolar disorder

(signs indicate manic stage)

Front 30

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

Back 30

Rish for injury related to impaired judgement.

(falls in the biological category in Maslow's)

Front 31

Which is the primary goal for a pt in a preliminary stage of recovery from substance abuse?

Back 31

To acknowledge that the pt has a problem.

Front 32

What is the goal of family therapy as a component of tx for a pt who has schizophrenia?

Back 32

Reduce family's stress level.

Front 33

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

Back 33

Establishing individual autonomy
(difficulty with self image and trusting themselves)

Front 34

Which is an appropriate expected outcome for a 5 yo child who is autistic and has a nursing dx of social isolation? The child will..

Back 34

Make attempts to offer toys to peers.

Front 35

An individual who has been discharged to a group home following a prolonged stay in a psychiatric institution is most likely to experience difficulty with which activity?

Back 35

Initiating a change in the daily schedule.

Front 36

What nursing dx takes priority for a pt with major depression who is being admitted to an inpt tx center?

Back 36

Risk for self-directed violence related to anger.

Front 37

Which behavior is characteristic of all types of personality disorders?

Back 37

Inflexible response to stress.

Front 38

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

Back 38

Orthostatic hypotension

(the result of alpha-adrenergic blockade of tricyclic antidepressants.)

Front 39

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

Back 39

To identify factors that may influence the pts behavior.

(identify the political leaders characteristics, actions, and circumstances)

Front 40

Which outcome best reflects resolution of a common symptom of post-traumatic stress syndrome? The pt..

Back 40

Sleeps through the night.

(inability to sleep thru the night or with nightmares are symptoms of PTSD)

Front 41

Which is the most important nursing intervention during the nurse's initial interaction with a pt who is experiencing auditory hallucinations?

Back 41

Determine what the voices are saying to the pt.

(so that the appropriate precautions can be provided if the voices direct pt to be violent or self destructive)

Front 42

Which behavior by a child who is emotionally disturbed is most indicative of a severe problem?

Back 42

Unresponsiveness to the environment.

(Indicates a severe problem and requires intervention)

Front 43

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

Back 43

Integrity

(The crisis of integrity versus despair occurs in older adults. Reminising therapy helps older adults successfully achieve integrity.)

Front 44

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

Back 44

Guided imagery

(A process in which a person is left to envision images that are calming and health enhancing)

Front 45

Which action would the nurse take in response to a pt whose manic behavior becomes calmer and more controlled?

Back 45

Have the pt participate in small, quiet groups.

Front 46

The nurse in the crisis center is talking on the phone with a pt who has suicidal thoughts. Which pt statement is the most effective no-suicide contract?

Back 46

"I will call you when I have thoughts of killing myself."

Front 47

A person with borderline personality disorder would most likely engage in self-destructive behavior if faced with which stressor?

Back 47

Abandonment by spouse.

(precipitated by rejection)

Front 48

Which nursing dx takes priority for a pt who has bipolar disorder?

Back 48

Risk for injury to self

Front 49

Which is an appropriate outcome for an eight-year-old child with Attention-Deficit/Hyperactivity disorder (ADHD) who has a low tolerance for frustration? The child will...

Back 49

Increase verbal expression of feelings to others.

Front 50

A newly admitted pt tells the nurse, "I don't feel comfortable here. NO one seems to like me." Which response by the nurse is an ex of the technique of reflecting?

Back 50

"You seem to have some concerns about being accepted here."

(Nurse conveys and observation of the pt to help pt better understand personal thoughts and feelings.)

Front 51

When adminitering an injection to a pt with inpaired liver function, the nurse should take special precautions to prevent which problem?

Back 51

Bleeding.

(Many pts with liver disease have clotting defects and are at risk for bleeding.)

Front 52

A baseline assessment of a pt receiving pancrelipase(Pancrease) for tx of chronic pancreatitis should include which nursing measure?

Back 52

Assess for pain with food.

(Pancrease is a replacement for pancreatic enzymes that helps to digest and absorb fat, protein, and carbs. The nurse would need to monitor whether the pt was having pain with meals to determine the effectiveness of the meds.)

Front 53

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

Back 53

Acarbose (Precose)

(Precose acts by delaying absorption of glucose in the intestinal tract)

Front 54

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

Back 54

Urinary output 60 mL in 4 hrs

(may indicate a complication. A urinary output of 30 mL/hr or greater is the acceptable outcome postoperatively)

Front 55

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

Back 55

Ammonia

(Lactulose acts to promote exretion of ammonia in the stool)

Front 56

Which response by a nursing asst indicates an understanding of the dietary needs of a pt who is recovering from pancreatitis?

Back 56

"Decaffeinated coffee is your best choice."

(Caffeine should be avoided because it increases pancreatic and gastric secretions.)

Front 57

Which nursing dx is appropriate for a pt with diabetes mellitus who is unable to control elevated glucose?

Back 57

Altered health maintenance

Front 58

A pt with diabetes mellitus is planning to begin an exercise program. Which statement by the pt indicates the need for further teaching?

Back 58

"If my blood sugar is over 250 mg/dL, excercise will lower it."

(This is a false statement)

Front 59

A referral for home care is indicated for a 60 yo pt recovering from acute pancreatitis. Which nursing intervention is essential for the home care agency to continue? The nurse should..

Back 59

Reinforce the importance of the pts fluid and nutrition intake.

(Pt should adhere to a high- carb, low-protein, and low-fat, elimiate alcohol, and avoid excessive use of spicy foods and caffeine.)

Front 60

By what mechanism does propranolol hydrochloride (Inderal) prevent hemorrhage from esophogeal varices?

Back 60

Decrease in portal hypertension.

(Inderal is a beta-blocking agent that acts to decrease portal pressure and has been shown to decrease esophogeal varices.)

Front 61

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

Back 61

Erythromycin estolate (Ilosone)

(Common side effects are nausea or vomiting, abd pain, diarrhea.

Front 62

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

Back 62

Assesses the pts ability to perform a reliable capillary puncture at regular intervals to monitor blood sugar.

Front 63

Which pt is at risk for developing cholelithiasis?

Back 63

A pt with diabetes mellitus.

Front 64

Which statement by a pt with ascites indicates that compliance with the prescribed dietary regimen may be difficult?

Back 64

"I drink water all day and I'm still thirsty."

(Pt with ascites has significant issues with sodium and water retention. )

Front 65

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

Back 65

Weighs himself once a week.

(Pt should monitor weight DAILY)

Front 66

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

Back 66

Hypocalcemia

Front 67

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

Back 67

Lipodystrophy

(a localized reaction at the site of insulin injections. If insulin is injected into scarred areas, absorption may be delayed.)

Front 68

How can the nurse help the pt with abd ascities accept the change in body image? The nurse should...

Back 68

Assist the pt to maximize her/his personal appearance.

Front 69

Which assessment of a stool characteristic indicates a problem following a choledochostomy?

Back 69

Clay colored

(any change in color could indicate complications)

Front 70

Which pt statement indicates an understanding of the initial recommended tx for signs and symptoms of hypoglycemia?

Back 70

"I will eat several hard candies."

(pt needs 15g of fast acting source of carbs and can meet this need by eating 6-10 pieces of hard candy)
(

Front 71

What causes pruritis in the pt with biliary cirrhosis of the liver?

Back 71

Retention of salts.

(biliary cirrhosis is the result of chronic biliary obstruction and infection)

Front 72

Which assesment finding in a pt with diabetes mellitus (type 1) is a clinical manifestation of diabetic neuropathy? The pt ...

Back 72

Walks with an unsteady gait.

(unsteady gait assoc with decreased sensation to light touch)

Front 73

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

Back 73

With the first bite of each main meal.

(Acarbose affects food absorption, so it must be taken immediately before a meal.)

Front 74

The nurse administers glucagon to a pt with diabetes mellitus experiencing a loss of consciousness. What is the typical therpeutic effect of this med?

Back 74

Transitory hyperglycemia

(glucagon is used to treat severe hypoglycemia. It accelerates the breakdown of glycogen to glucose in the liver, causing transitory hypergylcemia)

Front 75

Which information should the nurse include when instructing a pt who is scheduled for liver biopsy?

Back 75

Prior to the biopsy you will need blood work done to check for clotting.

(Prothrombin time, partial thromboplastin time, and platelet counts)

Front 76

A pt has a decreased erythropoietin production secondary to end stage renal disease (ESRD). Which nursing dx would be most appropriate for this pt?

Back 76

Activity intolerance related to fatigue.

(ESRD causes waste products to build in the blood at toxic levels. Fatigue is prominent body response to this toxicity, resulting directly from Erythropoietin production (anemia)).

Front 77

A pt with hyperthyroidism (Graves disease) has a nursing dx of altered nutrition; less than body requirements. Which pt outcome would be appropriate?

Back 77

Consumes a high-calorie, high-protein diet

(pt with Graves has a high metabolic rate and increased peristalsis).

Front 78

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

Back 78

To reduce the vascularity of the thyroid gland.

(Iodine prep such as Lugol's solution are administered to reduce blood loss by reducing vascularity and size of the thyroid gland.)

Front 79

Which nursing assessment is a priority for a pt with phechromocytoma?

Back 79

Vital sigs

(Pheochromocytoma is characterized by headache, diaphoresis, and palpitations. Also, could have high BP and other cardiovasc probs.)

Front 80

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

Back 80

Tracheostomy tray, suction apparatus, and IV calcium gluconate.

(Pt is at risk for breathing emergency because of swelling of throat, hematoma, or nerve injury).

Front 81

Why is it important to gradually introduce thyroid supplmentation to an older adult pt who has hypothyroidism?

Back 81

Cardiovascular changes put older adult pts at risk for angina and myocardial infarction and neuro side effects)

Front 82

A pt is receiving hemodialysis at an outpt dialysis center. Which problem assoc with this procedure must the nurse be prepared to quickly identify and to intervene if it develops?

Back 82

Leg cramps

(Muscle cramping occurs because of rapid fluids and electrolytes loss from the extracellular space.)

Front 83

A pt expresses concern about developing a moon face while on corticosteroid therapy. Which would be the best response by the nurse?

Back 83

"Most changes in appearance are temp and will disappear when therapy is no longer necessary."

Front 84

What is the expected effect of administering epoetin alfa (Epogen) to a pt with chronic renal failure? An increase in ..

Back 84

Red blood cells

(Epogen increases hematocrit, which is a measure of circulating RBCs).

Front 85

A pt has developed acute renal failure as a result of prolonged dehydration. Lab analysis reveals a potassium level of 6.4 mEq/L. Which med would be an appropriate tx modality?

Back 85

Sodium polystyrene sulfonate (Kayexalate)

(A cation-exchange resin used in gen cases of hyperkalemia. Can be used for acute renal failure).

Front 86

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

Back 86

Blood pressure

(Epogen may cause hypertension, especially early in tx).

Front 87

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

Back 87

Gigantism

Front 88

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

Back 88

Encourage pt to contact the National Assoc of Kidney Pts.

Front 89

A pt 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 89

Hyperphosphatemia

Front 90

Which strategy should the nurse consider when teaching an older adult pt who is newly diagnosed with diabetes about self monitoring of blood glucose?

Back 90

Include a significant other in the teaching.

Front 91

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

Back 91

Monitor serum glucose

Front 92

Which alteration in the integument is a clinical manifestation of chronic renal failure?

Back 92

Pruritis

(dry, flaky skin is common in chronic renal failure)

Front 93

Which statment by the pt with polycystic kidney disease indicates a need for further teaching?

Back 93

"if I follow this agressive tx plan, I might be cured of the disease."

(Polycystic kidney disease is chronic with no specific tx).

Front 94

A nursing asst reports that a pt with renal failure has gained 5 lbs since yesterday. Which is the most appropriate action by the nurse?

Back 94

Assess the pt's breath sounds.

(a build up of fluids could lead to heart failure or pulm edema.)

Front 95

Which factor contributes to the development of diabetes mellitus in a pt with Cushing's syndrome?

Back 95

Excessive cortisol causes increased gluconeogenesis.

Front 96

Which manifestation would the nurse be most likely to detect in the mental status of the pt with Cushing's syndrome?

Back 96

Emotional lability

Front 97

Which clinical manifestation should the nurse expect in a pt with hyperthyroidism?

Back 97

Weight loss

(in spite of increase in appetite and intake).

Front 98

Which statement made by the pt describes a clinical manifestation of Addison's disease?

Back 98

"I have been lightheaded."

(Hypotension and light headedness is common).

Front 99

Which lab finding supports the nursging diagnosis of fluid volume deficit in a pt with diabetes insipidus?

Back 99

Increased serum sodium

(pt is not excreting sodium)

Front 100

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

Back 100

"I felt warm, so I opened the window."

(A pt with hypothyroidism usually feels cold. This statement indicates an improvement attributed to Synthroid.)