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100 Cards in this Set

  • Front
  • Back
Which is the most appropriate outcome for a patient with depersonalization disorder who has a nursing diagnosis of social isolation? The patient will..
Express satisfaction with interactions with friends.
Which factor is associated with increased physical and mental health problems among older adults?
Having limited financial resources.
Setting limits with a patient who is manipulative benefits the patient in which way? The patient is able to ..
Gain self-empowerment in relationships with others
Which nursing measure is most important for a patient who is experiencing an acute episode of mania?
Prevent physicla exhaustion.
A patient with obsessive-compulsive disorder repetitively counts paper clips due to stress as a customer service rep. Which is the most appropriate nursing diagnosis to address this ritualistic behavior?
Altered role performance.
Which approach would best facilitate expression of emotions for a patient who is of Asian origin?
Keeping a journal. (In Asian cultures, expression of emotion is typically private.)
An adolescent patient with terminal cancer says, I just have no interest in doing anything or having any visitors." The patients comment is an example of which grief response?
Depression
Which symptom is most likely to be present in a preschooler who is depressed?
Social withdrawal
Regular engagement in which activity is most likely to lower anxiety ina patient who has chronic acute anxiety?
Physical excercise
Which individual would be the best candidate for short-term dynamic pscchotherapy? A client who...
Has post-traumatic stress disorder
Which result should the nurse expect when using reminiscence therapy with patients who are older adults?
Increased self esteem
According to the psychobiological theory of mental disorders, the mood disturbances of depression are related to deficiencies of which neurotranmitter?
Serotonin
Which symptom is associated with post-traumatic stress disorder?
Persistent feelings of detachment from others
A patient has been taking lithium for 2 weeks for manic phase of bipolar disorder. When the patient's lithium level reaches 1.2, which patient behavior can the nurse expect?
Modulation of mood and ability to solve problems. (Lithium levels of 0.4 - 1.3 mEq/L is the maintenance level)
How can the nurse evaluate effectiveness of the plan to treat a patient with anorexia nervosa who has a diagnosis of altered nutrition: less than body requirements?
Have the nursing assistant weigh the patient periodically.
What symptoms would the nurse expect to find in a patient with neuroleptic malignant syndrome?
High fever and muscle rigidity
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?
Take the patient to a quieter location.
Which behavior by a high school student is a sign that the student may be potentially suicidal?
The student misses classes and withdraws from the gymnastics team.
A patient is to receive electroconvulsive therapy (ECT) on an outpatient basis. Which information should be given to the patient prior to the initial ECT treatment.
Upon awakening after the treatment, you may feel groggy and confused.
Which is most important to consider in developing a care plan for a person experiencing unresolved anger?
When anger is turned inward, it can become depression.
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 arond?
"You've been talking of harming yourself, and I don't want anything to happen to you."
Which behavior may indicate impaired impulse control?
An adult accelerates rapidly when the traffic signal turns yellow.
A standard antipyschotic medication such as Haldol is most effective in modifying which symptom of schizophrenia?
Delusions of persecution
When caring for a patient with borderline personality disorder, the nurse hsould give priority to which patient outcome? The patient will...
Avoid self-mutilating behavior
According to Kohlberg's theory of moral development, which behavior is most descriptive of a child who has achieved internalization? The child...
Incorporates self-generated standards into his/her personality.
(Internalization is the developmental change from behavior that is externally controlled to behavior that is controlled by internal standards and principles.)
Which nursing measure should be used to address the vegetative signs of major depression?
Monitor the patient's eating and sleeping.
(Vegetative signs: change in bowel movements, eating habits, sleep disturbances, disinterest in sex)
A child who has autistic disorder is likely to display symptoms of the illness by which age?
4 months
(Definitive diagnosis at 3 yrs, but can display signs of lack of social responsiveness at 4 months)
Which action should be the focus of therapy for a nurse working with the family of a patient with anorexia nervosa?
Improving communication among family members
Which diagnosis tool is used to reveal structural and biochemical abnormalities associated with mental illness?
Position emission tomography (PET)
(Uses a radioactive tag material to trace physiological and biochemical changes in brain tissue.)
Which disorder is more likely to occur in male children than in female children?
Tourette's syndrome
Which statement by the patient with anorexia nervosa is an example of all-or-nothing thinking?
"If I have one piece of candy, I will eat every piece in the box."
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?
6-8 mg/L
Which information should the nurse plan to provide to the parents of a school-age child with Attention-deficit/Hyperactivity disorder who is receiving a central nervous system stimulant?
Administer medicine early in the day.
During a family therapy session, which statement is the nurse most likely to hear one family member say to another if the family boundaries are enmeshed?
"You should have known what I really meant when I said that."
To date, which disorder has the strongest evidence of genetic involvement?
Alzheimers disease (at least 4 genes involved with the transmission)
The nurse asks a patient how she is feeling today. The patient responds, "It is a beautiful day today. Beauty is in the eye of the beholder. I need to have my eyes checked. If I had a thousand checks I'd write them all to charity." This speech pattern reflects which type of alteration in though processes?
Flight of ideas.
Which behaviors in an 18-month old infant are clinical manifestations of autism?
Preoccupation with objects, self-stimulating behaviors, and absence of attachment.
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?
"I will adhere to a low-salt diet."
(Low sodium intake causes a relative increase in litium retention which can lead to toxicity)
The nurse should give priority to which intervention for a patient who has just completed an electroconvulsive therapy (ECT)treatment?
Monitor vital signs
(every 5 min until pt is awake)
What nursing diagnosis is the priority for a patient with major depression?
Altered nutrition: Less than body requirements related to lack of appetite.
A patient tells the nurse many details about his son's long illness and death. He says, "I feel no loss or pain." Which defense mechanism is the patient using?
Intellectualization

(Use of reasoning, logic, or words to prevent the person from experiencing feelings)
A patient admitted for substance abuse treatment says, "The only reason I"m here is to save my marriage. I can stop drinking anytime I want." The patient's response is an example of a symptom of which nursing diagnosis?
Ineffective denial
A patient presents with a history of unexplained pain in six different body areas. All medical tests are negative. This situation is characteristic of which condition?
Somatization disorder
(characterized by multiple physical complaints that persist for years involving any body system. Most often digestive, nervous, reproductive)
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...
Verbalize understanding that eating behaviors are maladapative.
A patient who is depressed has been neglecting to perform activities of daily living. Which nursing action by the nursing assistant is most likely to encourage the patient to bathe?
In a kind but firm manner, help the patient to bathe.
It is most important for the nurse to evaluate a patient who is manic in which area?
Nutritional status
A person with borderline personality disorder would most likely engage in self-destructive behavior if faced with which stressor?
Threat of separation or rejection
A patient with depression suddenly seems less depressed and more cheerful and active on the unit. What should be the nurse's response to this change?
Reassess the patient for suicidal potential.
Which characteristic should the nurse expect to find in a patient admitted with a diagnosis of borderline personality disorder?
Emotional instability

(instability of moods, interpersonal relationships, self-image, and behavior)
An outpatient who has been taking the tricyclic antidepressant amitriptylline (Elavil) 100 mg each morning for depression reports confusion and drowsiness. Which change should the nurse make in the patient's care plan? Instruct the patient to...
Take the daily dose at bedtime instead of in the morning.
(has a sedative effect)
A patient is prescribed an antidiabetic (oral hypglycemic) agent for control of diabetes mellitus (tpe 2), but needs help with the preparation of the medication. Which statement made by the caregiver indicates the need for additonal teaching about the medication?
"Since the patient can take a pill rather than insulin, the diabetes is less serious and won't cause as many complications."
What is the rationale for incorporating massage into the plan of care for a patient who has impaired liver function?
To promote mobilization of edema
The nurse is caring for an Asian American patient who is being treated for diabetes mellitus. The expected outcome is that the patient will participate in a theapeutic working relationship with the nurse. Which behavior best indicates that the outcome has been met?
Asks the nurse questions about insulin administration.
Which form of vitamins A, D, and E should be given to a patient with hepatic cirrhosis who is experiencing steatorrhea?
Water-soluble

(Steatorrhea causes problems with malabsorption, especially of fats and proteins)
What is the rationale for using propranolol hydrochloride (Inderal) in the management of patients with cirrhosis of the liver?
Prevent bleeding from esophageal varices.

(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.)
Which intervention shoud the nurse select for a patient with diabetes mellitus who is knowledgable about the disease and self-care but neglects to follow the diet or check blood sugar levels?
Plan to meet with the patient at frequent intervals.
Which test provides the most information when diagnosing chronic pancreatitis?
Endoscopic retrograde cholangiopancreatography (ERCP)
What nursing measure should the nurse perform for a patient with ascites?
Measure the patient's abdominal girth. (daily)
What is the purpose of administering pancrelipase (Pancrease)to a patient with pancreatitis?
To aid in digestion of fats, carbohydrates, and triglycerides.
Approximately what percent of a diet for a patient with diabetes mellitus should be in the form of carbohydrates?
50 - 60% should come from carbs
Which data in a patient's health history would place the patient at risk for the development of noninsulin-dependent diabetes mellitus (type 2)?
Height 5'2", weight 170lbs

(diagnosed in pts over 30, but sex is not a predisposing factor)
A patient recovering from hepatic encephalopathy is to be discharged from the hospital. What teaching should the nurse give the family to help them assess for signs of recurrent encephalopathy?
Obtain a sample of the patient's handwriting on a daily basis.
Which lab test should the nurse monitor during the treatment of diabetic ketoacidosis to avoid serious potential complication of rapid fluid infusion?
Serum potassium

(during rehydration, serum postassium drops.)
WIn setting priorities for the assessment of patients with diabetes mellitus (type 2), the nurse should recognize that which medication creates the greatest risk for a hypoglycemic reation?
Metformin + glyburide (Glucovance)
(risk of hypoglycemia)
Which co existing condition should the nurse recognize as a problem in the patient with acute pancreatitis?
Pleural effusion
When reviewing the physician's orders for a patient with pancreatitis, the nurse would seek clarification if which narcotic analgesic were listed?
Meperidine (Demerol)

(can cause central nervous system irritabilty)
Which clinical manifestation is most indicative of impending hepatic encephalopathy in a patient with liver failure?
Disorientation
Which nursing intervention will most likely achieve the goal of improving respiratory function for a patient with acute pancreatitis?
Maintain the patient in semi-fowlers postion to decrease pressure on the diaphragm.
Which type of medication should the nurse question in the order for a patient with end-stage hepatic dysfunction?
Sedatives
Which is an advantage of the glycosylated hemoglobin (HBA 1c) test over the fasting blood sugar test for patients with diabetes mellitus?
Allows an assessment of patient compliance with treatment regimen
(provides a record of blood sugar over the past 2-3 mo)
Postoperative nursing care for a patient who has a T-tube in place following an open cholecystectomy should include which intervention?
Monitor the stool for return of pigmentation.
What information would the nurse give the patient who has had a laparoscopic cholecystectomy about managing pain in the right shoulder?
"You should apply a heating pad for 15 min hourly."
Which statement by the patient shows that there is an accurate understanding of what an endoscopic retrograde cholangiopancreatography test (ERCP) involves?
"I will be given a sedative, followed by the oral insertion of a scope into the GI tract."
A patient is admitted with a diagnosis of cirrhosis of the liver related to alcohol abuse and exhibits clasic manifestations of the disease. The nurse should formulate which nursing diagnosis for this patient?
Fluid volume excess related to ascites
A patient with diabetes mellitus has serum glucose of 500 mg/dL, and elevated blood urea nitrogen (BUN) and pH of 7.40 with physical exam findings of hypotension, dry mucous membrance, tachycardia, and somnolence. These findings are consistent with...
Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

(HHNS will exhibit blood glucose > 500mg/dl, a normal pH, and elevated BUN and creatinine)
Which clinical manifestation would the nurse expect to observe in a patient with decreased erythropoetin production secondary to end-stage renal disease (ESRD)?
Shortness of breath
To improve the nutitional status of a patient with Graves disease, the nurse should include which action in the plan of care?
Provide the patient with a quiet atmosphere during meals.

(a pt with hyperthyroidism is often irritable and has difficult coping with stress)
The nurse should be concerned if a patient with renal calculi is consuming excessive amounts of which liquid?
Milk
Which finding should the nurse expect in a patient with hyperparathyroidism?
Fatigue

(
Which outcome does the nurse identify as most appropriate for the patient who is being treated for renal calculi? The patient ..
Maintains urinary output that is equivalent to fluid intake.
Which question yields the most pertinetn information for the nurse who is assessing a patient with acromegaly?
"Do you have pictures of yourself from youth to present?"
A patient with a thyroid storm has a nursing diagnosis of altered body temp. The nurse should give priority to which intervention?
Apply hypothermia blanket.

(will reduce pt's fever)
The nurse is teaching a pt with hypothyroidism about Levothyroxine sodium (Sythroid) therapy. The nurse should tell the pt that this therapy takes what length of time to achieve full effect?
10 days
to get a full level
The nurse is teaching a patient with pheochromocytoma about the disease process. What information shoudl be included?
It is caused by the patient's catacholamine producing tumor.
Which is a common nutrition-related problem found in a patient with moderate hypothyroidism?
Weight gain

(metabolism is below normal)
Which nursing intervention would be most likely to enhance the comfort of a pt with hyperthyroidism?
Provide a cool environment for the pt.
(have poor tolerance for heat)
A patient with hyperparathyroidism is encouraged to remain as physically active as possible because decreased mobility may lead to which problem?
Renal calculi
In caring for a patient with edema associated with nephrotic syndrome, the nurse must carefully monitor the use of diuretics for which reason?
Reduced plasma volume may precipitate acute renal failure.
(hypovolemic shock > renal failure)
The nurse assesses that a patient with adrenal insufficiency is dizy and is experiencing neuromuscular irritability and confusion. The nurse should associate these findings with which laboratory finding?
Hyponatremia

(common in adrenal insufficiency)
The nurse should give priority to which intervention for a patient with hyperthyroidism who is started on propranolol hydrochloride (Inderal)?
Monitor pulse and pulse pressure.
(it is a beta blocker...prescribed to reduce tachycardia and palpitations. could lead to CHF)
Which symptom is most characteristic of acute pyelonephritis?
Flank pain
Which nursing diagnosis is most appropriate for a patient with hyperthyroidism (Graves' disease), who develops exophthalmus?
Body image disturbance

(Exophthalmus..protrusion of the eyes)
A patient with renal calculi has returned to the clinic for a follow-up visit. Which statement by the client indicates to the nurse that additional teaching is necessary?
"My wife says I should take a multi vitamin and mineral tablet daily."

(should not take vitamins, particularly with Vit D and calcium)
A pt with hypothyroidism who is taking hormone replacement therapy may be at risk for the development of which health problem?
Hyperglycemia

(thyroid hormones increase blood glucose)
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?
Instruct the assistant to limit the patient's fluid intake. (to the amt of output)
What is a physiological effect of thyroxine (T4)
Increased neuromuscular response.
(makes the muscles more responsive to catecholamines)
Following a thyroidectomy, it is most important for the nurse to ask the patient which question to assess for bleeding?
"Do you have a feeling of fullness at your incision site?"
What is the expected effect of epoetin alfa in a patient with chronic renal failure?
Increase in hematocrit

(Epoetin Alfa is used to treat anemia)
What should the nurse expect to assess in the patient with Graves' disease?
Nervousness.
Older pts with hyperthyroidism commonly present with which clinical manifestation?
Diffuse pruritis

(pruritis..itching.. with dry skin is common is older pts. )