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137 Cards in this Set
- Front
- Back
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Grief experienced in advance of the event is called?
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Anticipatory Grief
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A subjective response of a person who has experienced the loss of a significant other through death is?
a) Mourning B) Dysfunctional Grief C) Perceived loss d) Bereavement |
Bereavement
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The state in which an individual or group experiences prolonged unresolved grief & engages in detrimental activities is?
a) Mourning B) Dysfunctional Grief C) Perceived loss d) Bereavement |
Dysfunctional Grief
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Emotional suffering often caused by bereavement is?
a) dysfunctional grief b) mourning c) bereavement d) grief |
Grief
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An actual or potential situation in which a valued ability, object, or person's inaccessible or changed so thit is perceived as no longer valuable is?
a) dysfunctional grief b) mourning c) bereavement d) loss |
Loss
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The process through which grief is eventually resolved or altered is?
a) dysfunctional grief b) mourning c) bereavement d) grief |
Mourning
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A loss experienced by one person but cannot be verified by others is referred to as:
a) Grief b) Anticipatory Loss c) Perceived loss d) Bereavement |
Perceived loss
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A type of loss that can be recognized by others?
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Actual Loss
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Loss experienced by one person but cannot be verified by others is ?
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Perceived Loss
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An emotional response to loss is?
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Grief
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An outward social expression of the loss is called?
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Mourning
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Age group that believes death is like sleeping and is reversible ?
a) 1 - 3 years b) 3 - 6 years c) 6 - 9 years d) 9 - 12 years |
3 - 6 years
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After a nurse questions a client about relationship abuse, the client responds that she is ready to leave the abusive relationship, although past attempts were not successful due to fear, lack of support, lack of confidence, and financial considerations. She asks the nurse for help. An example of perceived loss is:
a) Loss of partner b) Loss of dreams c) Loss of residence d) Loss of current lifestyle |
Loss of dreams
Perceived loss is experienced by one person but cannot be directly verified by others. Loss of partner, residence, and lifestyle can be seen and acknowledged by others, even if they are not favorable. Dreams are something of which only the client is aware. She may have dreamed of a happier relationship that she finally acknowledge was not forthcoming, or the dream may be of a different origin. Only the client knows. |
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A 22-year-old client with recent paraplegia lashes out and curses at the nurse about the breakfast meal. The nurse's best response is:
A) "I know you are angry, but I cannot let you make me become the object of your anger. I will send up the dietician." b) "This is not about breakfast. Tell me what you are really angry about." c) "I understand you are angry. I'll shut the door and let you cool off." d) "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?" |
"I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"
Acknowledging the client's anger and helping the client understand the source of the anger is helpful. Do not take the anger personally. Allow choices and control when possible. |
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The ability of an individual to cope with death is dependent upon a number of factors. Which person likely have the most difficulty coping with a death?
a) A parent whose 17-year-old child died in an auto accident the night before graduation b) A child of 8 years whose grandparent dies a week before a planned visit c) The spouse of an alcoholic who is killed in an automobile accident d) The grandparent of a child born with Tay-Sachs disease |
A parent whose 17-year-old child died in an auto accident the night before graduation
Many factors affect the grieving experience. These include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, social support systems, and the cause of the death. In our culture, the death of an older person is accepted more easily than that of a younger person. The death is more easily accepted if it is anticipated, and if the person who died did not contribute to the death. Usually, the closer the individual is to the person who died, the more difficult it is to cope with the death. |
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While the nurse is discussing a client's likely death with family members, one of the offspring inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is:
a) "Often, there is a lucid moment during the last hour that lasts about 15 minutes. First look for relaxation followed by clearing of the eyes, looking around, focusing on faces, and clearing of the throat. Call the others in at that time." a) "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." c) "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." d) "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with nuchal rigidity. Don't be alarmed when you hear a death rattle in the throat. " |
"You can expect more muscle relaxation and less movement.
Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." Muscles relax with decreased activity. Muscle rigidity is not a usual pattern. The gag reflex is lost, and mucus accumulates in the back of the throat. Vision is blurred. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected. |
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Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent takes this as proof that the family truly believes the accusation. This sets up a destructive cycle of family dysfunction. Which nursing diagnosis is most appropriate for this family?
a) Impaired family processes related to impaired adjustment b) Impaired adjustment related to loneliness c) Loneliness related to fear d) Dysfunctional grieving related to loss of relationships |
Impaired family processes related to impaired adjustment
The first part of the diagnostic statement reflects the concern at hand, while the second part is the etiology or cause. There are a number of concerns present in this scenario. Following the child's death, the whole family is impaired in processing the event, adjusting, and grieving. In addition, the parent is alienating the family with false accusations, resulting in lack of support, dysfunctional grieving, and loneliness. If the parent improved adjustment to the death, family processing would improve. |
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A family with five children experiences a stillbirth. While intervening with the family, one member expresses a view that causes special concern for the nurse. This person is:
a) A 3-year-old who wonders if the baby will come home after it gets better b) A 5-year-old who cries, believing the death occurred because the child drew with magic markers on one of the baby blankets c) A 13-year-old who assumes blame as punishment for shoplifting d) A 15-year-old who says, "I still can't believe it is true." |
A 13-year-old who assumes blame as punishment for shoplifting
A child of 3 does not understand the concept of death, or its permanence. A child of 5 may associate death with unrelated actions. A 15-year-old is expected to follow similar stages of grief, including denial |
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A client questions the nurse about the difference between a living will and power of attorney. The nurse's best response is:
a) A lawyer carries a living will, while a designated family member or friend carries out advanced directives. b) In a living will, the client specifies medical treatments to be carried out when incapable of making decisions, while durable power of attorney allows the client to include both treatments to be carried out and treatments to be omitted in the event of terminal illness. c) The living will indicates when a client wishes life support to be discontinued, while durable power of attorney give that power to another in the event of terminal illness. d) The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client. |
The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness.
Durable power of attorney legally appoints another to make those decisions on the behalf of the client. Physiological defining characteristics are the somatic aspects that describe the problem or diagnosis. In anxiety, sweaty palms and hyperventilation are the physiological characteristics, while decreased concentration, lack of focus, incoherence, and rigidity in thinking are all examples of cognitive ones. |
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A 90-year-old client expresses a wish to die at home after being told that an esophageal stricture prevents swallowing. The client refuses a feeding tube. The family fully supports this decision. The nurse plans to:
a) Call hospice care b) Call a rabbi c) Call a lawyer d) Call the coroner |
Call hospice care
Hospice care specializes in end-of life care. A rabbi is an important person during the end of life, but there is not an immediate need make this call. A lawyer or coroner is not necessary at this time. |
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Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is:
a) Preparing the body to look as clean and natural as possible b) Pulling the sheet over the patient's face until the family is comfortably seated in the room c) Humor is helpful in relieving stress. However, use humor only after family has left. d) Calling the physician to verify the time of death before taking the body to the morgue |
Preparing the body to look as clean and natural as possible
The body is to be handled with dignity at all times. This does not include using humor at this time After the body is cleaned and the linen freshened, the sheet is pulled to cover the patient's shoulders. Laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly. |
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While talking to adult children of a dying client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that the client was a parent who often showed love but followed it with criticism, anger, damaging accusations, and emotional abuse. The nurse suggests an intervention that may be helpful to the client and other family members. The most likely intervention to be helpful is:
a) Listening to relaxation tapes before visiting each other. If negative feelings arise, listen to the tapes together. b) Having a nurse present in the room at all times when one of them visits the client. The nurse will intervene with conflict resolution if problems arise. c) Assuring the client and children that the past no longer matters. The only time that matters is the present and the future. d) Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together. |
Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together.
Relaxation tapes help with stress reduction, but do not help resolve problems experienced by the client and children. Staffing needs do not permit a nurse to be with one client continually, and families require privacy as well. Assurance that the past no longer matters is an assurance lacking concrete properties. |
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An age where one begins to accept one's own mortality and seeks ways to prevent it:
a) adolescents b) young to middle adults c) middle adulthood d) older adults |
middle adulthood
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Concrete, magical thinking that results in guilt such as "I once told mommy I wish she were dead" is an example of:
a) dysfunctional grief b) perceived loss c) anticipatory grief d) uncomplicated grief |
anticipatory grief
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Actual or fear of potential loss of health, loss of independence, loss of a body part, loss of financial stability, loss of choice, and, or loss of mental function are all examples of?
a) perceived loss b) actual loss c) anticipatory grief d) uncomplicated grief |
anticipatory grief
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Grief from which survivors resort to self destructive behaviors such as suicide is called:
a) chronic grief b) perceived grief c) exaggereated grief d) normal grief |
exaggerated grief
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Symptoms of cognitive grief may include all the following EXCEPT:
a) dreams of deceased b) inability to concentrate c) fleeting tactile, olfactory, visual and auditory hallucinatory experiences d) guilt of self reproach |
guilt of self reproach
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A patient describes feeling muscle aches, tension, and insomnia after experiencing a loss. These are what type of symptoms:
a) emotional b) cognitive c) physical d) behavioral |
physical
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A patient describes feeling anger, helplessness & abandonment, after experiencing a loss. These are what type of symptoms:
a) emotional b) cognitive c) physical d) behavioral |
emotional
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A patient describes feeling impaired work performance, withdrawl, and changed relationships, after experiencing a loss. These are what type of symptoms:
a) emotional b) cognitive c) physical d) behavioral |
behavioral
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A patient describes feeling confusion, dreams about the deceased, and experiences fleeting tactile, olfactory, visual and auditory hallucinations. This patient is describing what type of symptoms:
a) emotional b) cognitive c) physical d) behavioral |
cognitive
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At what age does a child begin to realize that death is not reversible?
a) 3 yrs b) 6 yrs c) 9 yrs d) 12 yrs |
9 yrs
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Name 4 NDX's associated with grief?
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Anticipatory grieving
Dysfunctional grieving Interrupted family processes Impaired adjustment Risk for loneliness |
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CPR as we know it, was developed in the?
a) 1950's b) 1960's c) 1970's d) 1980's e) 1990's |
1960's
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A period in time when emphasis switched to disease prevention and curing disease rather than easing suffering was?
a) 1700 - 1760's b) 1760 - 1800's c) 1860 - 1900's d) 1900 - 1960's |
1900 - 1960's
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Decreased urine output, cold and mottled extremities, changes in vital signs, respiratory congestion that includes bubbling, and changes in breath patterns are?
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Eminent signs of death
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According to Kubler-Ross, the five stages of grieving are:
a) anger, denial, bargaining, depression, acceptance b) denial, bargaining, anger, depression, acceptance c) bargaining, anger, denial, acceptance, depression d) denial, anger, bargaining, depression, acceptance |
denial, anger, bargaining, depression, acceptance
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All of the following may be cnsidered normal or "healthy" types of grief EXCEPT
a) abbreviated grief b) anticipatory grief c) disenfranchised grief d) dysfunctional grief |
dysfunctional grief
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A brief sense of grief that is genuinely felt, but of which the loss is not sufficiently important or may have been replaced:
A) dysfunctional grief B) anticipatory grief C) disenfranchised grief D) abbreviated grief |
abbreviated grief
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When an individual is unable to acknowledge a loss to other persons it is identified as:
a) abbreviated grief b) disenfranchised grief c) dysfunctional grief d) exaggerated grief |
disenfranchised grief
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When many of the normal symptoms of grief are suppressed, and other effects, including somatic, are experienced instead, it is called:
a) disenfranchised grief b) unresolved grief c) inhibited grief d) dysfunctional grief |
inhibited/dysfunctional grief
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A patient tells you that in their culture, a dead person may not be left alone before burial. Your hospital policy states that after 6:00pm when mortuaries are closed, bodies are to be stored in the hospital morgue refridgerator until the next day. The nurse should?
a) gently explain the policy to the family, andd then implement policy b) Inquire to the nursing supervisor as to how an exception to the policy can be made c) call the patients physician for advice d) Move the deceased to an empty room and assign an aide to stay with the body |
Inquire to the nursing supervisor as to how an exception to the policy can be made
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While waiting for the grown children of a deceased patient to arrive, the shift has changed. The oncomming nurse has never met the patient or family. It would be most appropriate for the nurse to greet the family by saying:
a) I'm very sorry for your loss b) I'll take you to view the body c) I didn't know your father but Im sure he was a wonderful person d) How long will you want to stay with your father? |
I'm very sorry for your loss
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Which of the following is true for the patient with a DNR order?
a) The patient may no longer make decisions regarding his or her own health care b) The patient and family recognize that the patient will most likely die within the next 48 hours c) Nurses will continue to implement all treatments focused on comfort and symptom management d) A DNR order in place from a previous admission is valid for this and subsequent admissions |
Nurses will continue to implement all treatments focused on comfort and symptom management
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At which age will a child begin to accept that he or she will die someday?
a) less than 5 yrs old b) 5-9 yrs c) 9-12 yrs d) 12-18 yrs |
9-12 years old
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248. Which task should be assigned to the nursing assistant?
A. Placing the client in seclusion B. Emptying the Foley catheter of the preeclamptic client C. Feeding the client with dementia D. Ambulating the client with a fractured hip |
Feeding the client with dementia
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NCLEX - A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. |
Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
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NCLEX - A client is brought to the emergency room by the police. He is combative and yells, "I have to get out of here. They are trying to kill me." Which assessment is most likely correct in relation to this statement?
A. The client is experiencing an auditory hallucination. B. The client is having a delusion of grandeur. C. The client is experiencing paranoid delusions. D. The client is intoxicated. |
The client is experiencing paranoid delusions.
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NCLEX - The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
A. Hematuria B. Muscle spasms C. Dizziness D. Nausea |
Hematuria
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NCLEX - A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
A. Placing mirrors in several locations in the home B. Placing a picture of herself in her bedroom C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on D. Alternating healthcare workers to prevent boredom |
Placing simple signs to indicate the location of the bedroom, bathroom, and so on
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NCLEX - The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
A. 30 min before meals B. With each meal C. In a single dose at bed D. 60 minutes after meals |
With each meal
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NCLEX - Which action by the nurse indicates understanding of herpes zoster?
A. The nurse covers the lesions with a sterile dressing. B. The nurse wears gloves when providing care. C. The nurse administers a prescribed antibiotic. D. The nurse administers oxygen. |
The nurse wears gloves when providing care.
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NCLEX - An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
A. 14 pounds B. 16 pounds C. 18 pounds D. 24 pounds |
24 pounds
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NCLEX - A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
A. Palms rest lightly on the handles B. Elbows are flexed 0° C. Client walks to the front of the walker D. Client carries the walker |
Palms rest lightly on the handles
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NCLEX - A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
A. Take the medication w/milk B. Report chest pain. C. Remain upright after taking for 30 minutes. D. Allow 6 weeks for optimal effects. |
Report chest pain
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NCLEX - Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
A. 16-year-old female with scoliosis B. 12-year-old male with a fractured femur C. 10-year-old male w/sarcoma D. 6-yr-old male w/osteomylitis |
12-year-old male with a fractured femur
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NCLEX - The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
A. Bleeding on the dressing is 3cm in diameter. B. The client has a temp. of 6°F. C. The client's hematocrit is 26%. D. The urinary output has been 60 during the last 2 hours. |
The client's hematocrit is 26%.
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NCLEX - The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to:
A. Lack of exercise B. Hormonal disturbances C. Lack of calcium D. Genetic predisposition |
Hormonal disturbances
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NCLEX - The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
A. Pain B. Disalignment C. Cool extremity D. Absence of pedal pulses |
Disalignment
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NCLEX - The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
A. Low birth weight B. Large for gestational age C. Preterm birth, but appropriate size for gestation D. Growth retardation in weight and length |
Low birth weight
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NCLEX - The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
A. Hamburger pattie, green beans, French fries, and iced tea B. Roast beef sandwich, potato chips, baked beans, and cola C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea D. Fish sandwich, gelatin with fruit, and coffee |
Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
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NCLEX - A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
A. Estrogen levels are low. B. Lutenizing hormone is high. C. The endometrial lining is thin. D. The progesterone level is low. |
Lutenizing hormone is high.
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NCLEX - A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
A. High fever B. Nonproductive cough C. Rhinitis D. Vomiting and diarrhea |
High fever
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NCLEX - A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain |
Risk for aspiration
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NCLEX - A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
A. Ask the parent/guardian to leave the room when assessments are being performed. B. Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital. C. Ask the parent/guardian to room-in with the child. D.If the child is screaming, tell him this is inappropriate behavior. |
Ask the parent/guardian to room-in with the child.
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NCLEX - The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
A. "It is okay to give my child white grape juice for breakfast." B. "My child can have a grilled cheese sandwich for lunch." C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." D. "For a snack, my child can have ice cream." |
"We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."
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NCLEX - The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. B. The child should be allowed to instill his own eyedrops. C. The mother should be allowed to instill the eyedrops. D. If the eye is clear from any redness or edema, the eyedrops should be held. |
The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
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NCLEX - The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain |
The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
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NCLEX - The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort |
File a formal reprimand
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NCLEX - Which information should be reported to the state Board of Nursing?
A. The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay. D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. |
The narcotic count has been incorrect on the unit for the past 3 days.
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NCLEX - Which assignment should not be performed by the licensed practical nurse?
A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Starting a blood transfusion |
Starting a blood transfusion
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NCLEX - The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
A. Negligence B. Tort C. Assault D. Malpractice |
Malpractice
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NCLEX - The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
A. The client with Cushing's disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema |
The client with Cushing's disease
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NCLEX - The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client's vital signs. |
The nurse wears gloves to take the client's vital signs
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NCLEX - The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
A. Pain beneath the cast B. Warm toes C. Pedal pulses weak and rapid D. Paresthesia of the toes |
Paresthesia of the toes
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NCLEX - The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
A. The client selects a balanced diet from the menu. B. The client's hemoglobin and hematocrit improve. C. The client's tissue turgor improves. D. The client gains weight. |
The client gains weight.
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NCLEX - A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia |
Laryngeal edema
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NCLEX - Which selection would provide the most calcium for the client who is 4 months pregnant?
A. A granola bar B. A bran muffin C. A cup of yogurt D. A glass of fruit juice |
A cup of yogurt
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NCLEX - The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:
A. Place the client in Trendelenburg position B. Increase the infusion of Dextrose in normal saline C. Administer atropine intravenously D. Move the emergency cart to the bedside |
Increase the infusion of Dextrose in normal saline
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NCLEX - The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?
A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception |
Fluid volume deficit
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NCLEX - The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
A. Decreased urinary output B. Hypersomnolence C. Absence of knee jerk reflex D. Decreased respiratory rate |
Hypersomnolence
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NCLEX - The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
A. "You know you had breakfast 30 minutes ago." B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse." C. "I'll get you some juice and toast. Would you like something else?" D. "You will have to wait a while; lunch will be here in a little while." |
"I'll get you some juice and toast. Would you like something else?"
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NCLEX - The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
A. Chronic fatigue syndrome B. Normal aging C. Sundowning D. Delusions |
Sundowning
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NCLEX - The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
A. Agnosia B. Apraxia C. Anomia D. Aphasia |
Apraxia
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NCLEX - The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
A. Diabetes B. Prinzmetal's angina C. Cancer D. Cluster headaches |
Prinzmetal's angina
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NCLEX - A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
A. Call security for assistance and prepare to sedate the client. B. Tell the client to calm down and ask him if he would like to play cards. C. Tell the client that if he continues his behavior he will be punished. D. Leave the client alone until he calms down. |
Call security for assistance and prepare to sedate the client.
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NCLEX - The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
A. 30 minutes before meals B. With each meal C. In a single dose at bedtime D. 30 minutes after meals |
With each meal
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NCLEX - The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
A. Roast beef sandwich, potato chips, pickle spear, iced tea B. Split pea soup, mashed potatoes, pudding, milk C. Tomato soup, cheese toast, Jello, coffee D. Hamburger, baked beans, fruit cup, iced tea |
Split pea soup, mashed potatoes, pudding, milk
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NCLEX - The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
A. Feet B. Neck C. Hands D. Sacrum |
Neck
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NCLEX - The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
A. Macaroni and cheese B. Shrimp with rice C. Turkey breast D. Spaghetti |
Turkey breast
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NCLEX - The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
A. Roast beef, gelatin salad, green beans, and peach pie B. Chicken salad sandwich, coleslaw, French fries, ice cream C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie D. Pork chop, creamed potatoes, corn, and coconut cake |
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
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NCLEX - The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
A. Palpate the spleen B. Take the blood pressure C. Examine the feet for petechiae D. Examine the tongue |
Examine the tongue
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NCLEX - An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
A. Conjunctiva of the eye B. Soles of the feet C. roof of the mouth D. Shins |
Roof of the mouth
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NCLEX - The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
A. BP 146/88 B. Respirations 28 shallow C. Weight gain of 10 pounds in 6 months D. Pink complexion |
Respirations 28 shallow
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NCLEX - A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
A. Sexual dysfunction related to radiation therapy B. Anticipatory grieving related to terminal illness C. Tissue integrity related to prolonged bed rest D. Fatigue related to chemotherapy |
Sexual dysfunction related to radiation therapy
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NCLEX - The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client |
Check the vital signs
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NCLEX - A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
A. Place the client in a sitting position with the head hyperextended B. Pack the nares tightly with gauze to apply pressure to the source of bleeding C. Pinch the soft lower part of the nose for a minimum of 5 minutes D. Apply ice packs to the forehead and back of the neck |
Pinch the soft lower part of the nose for a minimum of 5 minutes
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Commonly used enemas that can cause the retention of sodium are?
a) hypotonic b) hypertonic c) isotonic d) oil |
hypertonic
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Enemas that distend the colon, stimulate peristalsis and soften feces are ?
a) hypertonic & hypotonic b) hypotonic & isotonic c) isotonic & soap suds d) isotonic & oil |
hypotonic & isotonic
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Enemas used to distend the colon and irritate the mucosa are?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
soapsuds
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Enemas having the shortest onset of action are typically?
a) hypotonic b) hypertonic c) isotonic d) oil |
hypertonic
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Enemas that act primarily to draw water into the colon are?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
hypertonic
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Enema's containing 90-120mL of solution (e.g., sodium phosphate) are called?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
hypertonic
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Enema's containing 500-1000mL of tap water are?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
hypotonic
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Types of enemas are classified into which of the following groups?
a) hypertonic; hypotonic; isotonic; soapsuds b) hypertonic; hypotonic; isotonic; oil; soapsuds c) hypertonic; hypotonic; isotonic; oil d) cleansing; carminative; retention; return-flow |
cleansing; carminative; retention; return-flow
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A Fleet enema is ?
a) hypertonic b) hypotonic c) isotonic |
hypertonic
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A Fleet enema is a?
a) cleansing enema b) carminative enema c) retention enema d) return-flow enema |
cleansing enema
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Type of enema that is considered the safest is?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
isotonic
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Enemas that should not be repeated due to potential circulatory overload are?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
hypotonic
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Enemas that exert the same osmotic pressure as the interstitial fluid surrounding the colon are?
a) hypotonic b) hypertonic c) isotonic d) soapsuds |
isotonic
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Enemas administered primarily to expel flatus are?
a) cleansing enema b) carminative enema c) retention enema d)return-flow enema |
carminative enema
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An enema that introduces oil or medication into the rectum and sigmoid colon is a?
a) cleansing b) carminative c) retention d) return-flow |
retention enema
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Isotonic enemas are considered the safest because?
a) they exert the same osmotic pressure as the interstitial fluid surrounding the colon so fluid does not move in to or out of the colon b) used only to clean the rectum and sigmoid colon c) it exerts a lower osmotic pressure than the surrounding interstial fluid causing water to move from the colon into the interstitial space d) they contain phosphate and normal saline solution |
they exert the same osmotic pressure as the interstitial fluid surrounding the colon so fluid does not move in to or out of the colon
b) used only to clean the rectum and sigmoid colon c) it exerts a lower osmotic pressure than the surrounding interstial fluid causing water to move from the colon into the interstitial space |
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Enemas that introduce oil or medications into the rectum and sigmoid colon are referred to as?
a) cleansing b) carminative c) retention d) return-flow |
retention
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An adult experoiencing constipation should have a daily fluid intake of ?
a) 1000-1500mL b) 1500-2500mL c) 2500-3000mL |
2500-3000mL
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Types of cleansing enemas to promote complete evacuation of feces from the colon are?
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Tap water
– Normal saline – Fleets – Soapsuds |
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Tap water, normal saline, Fleet,and soapsud enemas are used to?
a) Stimulate peristalsis by infusion of large volumes of fluid b) soften and lubricate the stool mass |
Stimulate peristalsis by infusion of large volumes of fluid
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Kayexalate enemas are given for?
a) to place radio-opaque materials into the colon for xray visualization b)reduce high potassium levels c) soften & lubricate stool mass d) diagnostics tests |
reduce high potassium levels
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Harris flush enemas?
a) expect that the instilled fluid will flow back into the enema container b) also called Return flow enemas c) Used to help mobilize pocketed intestinal gas d) all of the above |
all of the above
expect that the instilled fluid will flow back into the enema container are also called Return flow enemas are used to help mobilize pocketed intestinal gas |
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Digital disimpaction always requires a physician's order?#
True? False? |
False
Be aware that some facilities require a physician order for digital disimpaction In some facilities this is considered a nursing judgment. |
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Clients should be taught that reepeatedly ignoring the sensation of needing to defecate could result in?
a) constipation b) diarrhea c) incontinence d) hemorrhoids |
constipation
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Which of the following statements from an older adult who is prone to constipation indicates a need for increased teaching?#
a) I need to drink 1 & 1/2 to 2 quarts of liquids each day b) I should take a laxative such as milk of magnesia if I dont have a stool in 24 hours c) If my bowel pattern changes on it's own I should call you d) Eating my meals at the same time everyday increases the chance that i will have regular bowel movements |
I should take a laxative such as milk of magnesia if I dont have a stool in 24 hours
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A client will be undergoing a sigmoidoscopy requiring visualization of the anus, rectum, and sigmoid colon. The nurse expects the preparation to include which type od enema?
a) oil retention# b) return flow c) high, large volume d) Low, small volume |
Low, small volume
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While assessing an established colostomy, the nurse reports it as an unusual finding if?
a) the stoma extends 1/2" above the abdomen b) the skin under the appliance looks red briefly after removing the appliance c) the stoma color is deep red-purple d) an ascending colostomy delivers liquid feces |
the stoma color is deep red-purple
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An appropriate goal for clients with diarrhea thought to be a result of of an antibiotic given to treat an upper respiratory infection would be which of the following?
a) the client will wear a medic-alert bracelet for antibiotic allergy b) the client will return to his or her previous fecal elimination pattern c) the client verbalizes the need to take an antidiarrheal medication every 4 hours around the clock d) the client verbalizes the need to increase intake of insoluble fiber such as grain and cereals |
the client will return to his or her previous fecal elimination pattern
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You are presenting information at the community health fair about normal defecation patterns across the lifespan. Which of the following factors would not be part of the discussion?
a) Diet b) Fluid intake and output c) Medications d) Gender |
Gender
There is no relationship noted between gender and defecation pattern. Diet, fluids, and medications all can affect amount, consistency, or pattern of defecation. |
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The elderly population is known to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would identify the following facts as true except:
a) Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. b) Habitual use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced. c) Laxatives may interfere with fluid and electrolyte balance. d) Laxatives increase the absorption of certain vitamins. |
Laxatives increase the absorption of certain vitamins.
Laxatives decrease the absorption of vitamins. The remaining facts are true. |
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You encounter a 75-year-old client in the Emergency Department, with complaints of nausea, diarrhea, and anorexia. He has been evaluated, and it is determined that he can be treated at home. In discussing the guidelines of managing diarrhea, you know your client understands his care measures when he says:
a) "I will drink two glasses of water a day to prevent dehydration." b)"I will drink tea when I get home." c) "I will increase foods with fiber, like oatmeal." d) "I will eat fried chicken for supper." |
"I will increase foods with fiber, like oatmeal."
Increasing roughage (fiber) in the diet helps to add bulk to the stool. Eight glasses of water remains the recommended fluid recommendation, although there is some disagreement. Beverages with caffeine, like tea, and fatty foods like fried chicken aggravate diarrhea. |
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A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon. The type of stool that the client can expect from this stoma is:
a) Liquid that cannot be regulated B) Malodorous and mushy drainage C) Increasingly solid D) Liquid fecal drainage |
Increasingly solid
Stool in the descending colon is often formed, and the tissue can be trained for periodic defecation. Liquid stool and malodorous stool that cannot be controlled is found within the ascending colon. Malodorous, mushy stool is noted in the transverse colon. Output is always expected at some point in time from ostomies as evidence of their functioning. |
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After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include:
A) Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection B) Nothing can be done about the concerns of odor with the appliance. C) Ordering appliances through the client's health care provider D) The appliance will not be needed when traveling. |
Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection
Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies available for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, aplliances are almost always worn throughout the day and when traveling. |
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At the local wellness fair, you are asked to share information on having healthy bowel life. Included in this area is the topic of having a healthy defecation. You would include which of the following information as appropriate action to follow?
A) Eliminating high-fiber foods in your diet B) Defecating only once a day. Ignore any other urges. C) Establishing a regular exercise regimen D) Drinking four glasses of water a day |
Establishing a regular exercise regimen
Exercise helps to stimulate muscle functioning and metabolic activity, thus promoting healthy defecation. High-fiber foods are encouraged in the diet of this client. Do not avoid the urge to defecate, because this conditioned reflex tends to weaken or is ultimately lost. Six to eight glasses of water are recommended to maintain fluid balance in the body. |
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An 80-year-old client is in the Emergency Department. The client complains of diarrhea and vomiting for the past two days. In assessing the client, you note that his skin is dry and can be tented, he has lost eight pounds, and is itchy. Which NANDA diagnosis would be most appropriate to use with this client in making his plan of care?
a) Risk for deficient fluid volume related to prolonged diarrhea and vomiting b) Risk for fluid volume excess related to prolonged diarrhea and vomiting c) Risk for normal fluid volume related to prolonged diarrhea and vomiting d) Risk for hidden fluid related to prolonged diarrhea and vomiting |
Risk for deficient fluid volume related to prolonged diarrhea and vomiting
This client is showing signs of dehydration. The first answer is the only appropriate answer. |
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When using a rectal tube in helping a client expel flatulence, the most appropriate intervention to be followed by the nurse is:
a) Have client in the supine position b) Insert rectal tube, no lubrication needed c) Leave tube in for one hour d) Encourage the client to assume various positions in bed once the tube is inserted. |
Encourage the client to assume various positions in bed once the tube is inserted.
Varying the position from side-lying to sitting to supine, etc., helps the client to expel flatus. The side-lying position is recommended for use during insertion. Lubrication of the tube helps to ease the insertion process and prevent damage to the tissue. The tube should not be left in the client for more than 30 minutes, to avoid irritation to the rectal mucosa. |
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Your client has had a stroke, and can no longer move her bowels on her own accord. A bladder-training program is to be established for her. Before beginning this program, your client and her family members must understand what is involved with this care. Which of the following would be the most appropriate directions or information to share?
a) Maintain the daily routine for six weeks b) Only allow client to defecate once a day c) Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis d) Fluid intake, decreased fiber in diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defection on a regular basis. |
Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis
The best results can be obtained by inserting the suppository 30 minutes before the client's usual defecation time, or when the peristaltic action is greatest. The daily routine in bowel training is recommended to be 2-3 weeks. When the client experiences the urge to defecate, assist the client to the toilet/commode/bedpan to defecate. Fluid intake, increased fiber in the diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defecation on a regular basis. |
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You have just completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments?
a) Type of solution b) Length of time solution retained c) Relief of flatus and abdominal distention d) Amount of return |
Type of solution
Length of time solution retained Relief of flatus and abdominal distention Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented |
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Grief experienced in advance of the event is:
a) bereavement b) dysfunctional grieving c) anticipatory grieving d) mourning |
anticipatory grieving
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A subjective response of a person who has experienced the loss of a significant other through death is:
a) bereavement b) dysfunctional grieving c) anticipatory grieving d) mourning |
bereavement
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