1 FUNDAMENTALS OF NURSING NCLEX RN EXAM PRACTICE Q&A $25.45 Add To Cart
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Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 8| 75 Questions 1. 1. Question The best explanation of what Title VI of the Civil Rights Act man... [Show More] dates is the freedom to: o A. Pick any physician and insurance company despite one’s income. o B. Receive free medical benefits as needed within the county of residence. o C. Have equal access to all health care regardless of race and religion. o D. Have basic care with a sliding scale payment plan from all healthcare facilities. Incorrect Correct Answer: C. Have equal access to all health care regardless of race and religion. Title VI of the Civil Rights Act of 1964 states that “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” o Option A: The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health. Through this bill, the client may choose the primary care physician he wants from his plan’s network. o Option B: Since the Patient’s Bill of Rights was enacted, the Affordable Care Act has provided additional rights and protections. The health care law covers preventive care at no cost. Clients may be eligible for recommended preventive health services without a copayment. o Option D: Under the Patient’s Bill of Rights, a client’s premium dollars are ensured to be spent on primary healthcare, not on administrative costs. Also, the bill removes insurance company barriers to emergency services that are outside of their health plan’s network. 2. 2. Question Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to: o A. Include care that is culturally congruent with the staff from predetermined criteria. o B. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices. o C. Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care. o D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices. Incorrect Correct Answer: D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices Without understanding one’s own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific for this client. o Option A: As nurses strive to learn more about becoming culturally sensitive nurses, they should also let others know what they are doing and why. Encourage co-workers to provide more culturally competent care. Approach sharing awareness with openness and positivity, rather than from a critical point of view. o Option B: Cultural competency in the health care sector supports positive patient outcomes and improves medical research accuracy. Cultural competence is learning about how cultural differences may impact healthcare decisions and being able to modify care to align with that patient’s culture. o Option C: Active listening in the healthcare community is imperative, especially when individuals of different racial or cultural backgrounds are involved. It’s important that patients feel heard and validated, particularly when they are in a vulnerable position. 3. 3. Question Which factor is least significant during assessment when gathering information about cultural practices? o A. Language, timing o B. Touch, eye contact o C. Biocultural needs o D. Pain perception, management expectations Incorrect Correct Answer: C. Biocultural needs Cultural practices do not influence biocultural needs because they are inborn risks that are related to a biological need and not a learned cultural belief or practice. Culturally competent healthcare professionals learn about different groups and the values that drive them. They develop nonjudgmental acceptance of cultural and noncultural differences in patients and coworkers, using diversity as a strength that empowers them to achieve mutually acceptable healthcare goals. o Option A: When a patient doesn’t speak English and there is no interpreter, spend more time visiting to allay patients’ anxiety. Learn key phrases from the family and use flashcards to enhance communication. When all else fails, sign language does work. Remember that making the effort shows the patient that you care. You are using the language of the heart and building trust. o Option B: Both the clinician and the interpreter must pay particular attention to nonverbal feedback during communication with the patient to ensure understanding of the patient’s concerns and desires. During the exchange, the clinician and the interpreter must be able to convey caring and support to gain patients’ confidence and trust, particularly when they are revealing sensitive information. o Option D: Culture influences patients’ perceptions of illness, pain, and healing. These perceptions may conflict with clinicians’ views based on the medical model. Keep an open mind and listen actively to what patients say about their illness. 4. 4. Question Transcultural nursing implies: o A. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate. o B. Working in another culture to practice nursing within their limitations. o C. Combining all cultural beliefs into a practice that is a non-threatening approach to minimize cultural barriers for all clients’ equality of care. o D. Ignoring all cultural differences to provide the best-generalized care to all clients. Incorrect Correct Answer: A. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate Transcultural care means that by understanding and learning about specific cultural practices the nurse can integrate these practices into the plan of care for a specific individual client who has the same beliefs or practices to meet the client’s needs in a holistic manner of care. o Option B: Nurses should explore new ways of providing cultural care in multicultural societies, understand how culture affects health-illness definitions, and build a bridge for the gap between the caring process and the individuals in different cultures. o Option C: The individuals’ beliefs about health, attitudes, and behaviors, past experiences, treatment practices, in short, their culture, play a vital role in improving health, preventing and treating diseases. Health workers must collect cultural data to understand the attitudes of coping with illness, health promotion, and protection. o Option D: Nurses should offer acceptable and affordable care for the individuals under the conditions of the day. Knowing what cultural practices are done in the target communities and identifying the cultural barriers to offering quality health care positively affects the caring process. 5. 5. Question What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should: o A. Allow the family to provide care during the hospital stay so no rituals or customs are broken. o B. Identify how these cultural variables affect the health problem. o C. Speak slowly and show pictures to make sure the client always understands. o D. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital. Incorrect Correct Answer: B. Identify how these cultural variables affect the health problem. Without assessment and identification of the cultural needs, the nurse cannot begin to understand how these might influence the health problem or health care management. Culture is influential at many levels in health, ranging from the formation of new diagnostic groups to the diagnosis of disease to the determination of what is called a disease or no symptoms and disease cues o Option A: The transcultural approach should be considered in a wide range of subjects, starting from asking if there are any religious practices to be followed or done by the patient during the hospitalization, and writing the signs in the hospital in two different languages. o Option C: Health culture is concerned with every individual’s or the society’s patterns of living, celebrating, being happy in life, suffering, and dying. It is not enough for the individual to acquire only health-related information, but basic skills such as comprehending health-related values, developing a healthy lifestyle, and self-evaluation must be developed. o Option D: The environment is an integral part of the culture. Individuals as physical, ecological, sociopolitical, and cultural beings are continuously interacting with each other. Nurses may have to intervene in the patient and family relationship because of frequent bureaucratic arrangements and procedures. 6. 6. Question Which activity would not be expected by the nurse to meet the cultural needs of the client? o A. Promote and support attitudes, behaviors, knowledge, and skills to respectfully meet the client’s cultural needs despite the nurse’s own beliefs and practices. o B. Ensure that the interpreter understands not only the language of the client but feelings and attitudes behind cultural practices to make sure an ethical balance can be achieved. o C. Develop structure and process for meeting cultural needs on a regular basis and means to avoid overlooking these needs with clients. o D. Expect the family to keep an interpreter present at all times to assist in meeting the communication needs all day and night while hospitalized. Incorrect Correct Answer: D. Expect the family to keep an interpreter present at all times to assist in meeting the communication needs all day and night while hospitalized It is not the family’s responsibility to assist in the communication process. Many families will leave someone to help at times, but it is the hospital’s legal obligation to find an interpreter for continued understanding by the client to make sure the client is fully informed and comprehends in his or her primary language. o Option A: When caring for a patient from a culture different from the nurse’s own, she needs to be aware of and respect his cultural preferences and beliefs; otherwise, he may consider the nurse insensitive and indifferent, possibly even incompetent. But beware of assuming that all members of any one culture act and behave in the same way; in other words, don’t stereotype people. o Option B: Establishing an environment where cultural differences are respected begins with effective communication. This occurs not just from speaking the same language, but also through body language and other cues, such as voice, tone, and loudness. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires facilities to have interpreters available, so every facility should make a list available. o Option C: Thinking about one’s beliefs and recognizing one’s own cultural bias and worldview will help understand differences and resolve cultural and ethical conflicts one may face. But while caring for this patient, promote open dialogue and work with him, his family, and health care providers to reach a culturally appropriate solution. For example, a patient who refuses a routine blood transfusion might accept an autologous one. 7. 7. Question Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: o A. American Nurses Association’s (ANA’s) Code of Ethics o B. Nurse Practice Act (NPA) written by state legislation o C. Standards of care from experts in the practice field o D. Good Samaritan laws for civil guidelines Incorrect Correct Answer: A. American Nurses Association’s (ANA’s) Code of Ethics This set of ethical principles provides the professional guidelines established by the ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to establish rules and then incorporate guidelines for accountability and responsibility of each nurse within the practice setting. o Option B: Every state and territory in the US sets laws to govern the practice of nursing. These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws. Fifty states, the District of Columbia and 4 United States (US) territories, have state boards of nursing (BON) that are responsible for regulating their individual NPA. o Option C: Professional standards describe the competent level of care in each phase of the nursing process. They reflect a desired and achievable level of performance against which a nurse’s actual performance can be compared. The main purpose of professional standards is to direct and maintain a safe and clinically competent nursing practice. o Option D: Good Samaritan laws have their basis on the idea that consensus agreement favors good “public policy” to limit liability for those who voluntarily perform care and rescue in emergency situations. It is well known that medical emergencies outside of the umbrella “medical setting” or “clinical environment” are common. [Show Less]
Fundamentals of Nursing NCLEX RN Exam Practice Q&A | 75 Questions 1. 1. Question The most important nursing intervention to correct skin dryness is: o ... [Show More] A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. o B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. o C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. o D. Avoid bathing the patient until the condition is remedied, and notify the physician. Incorrect Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing. o Option B: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin. o Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol. o Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from the skin. Limit baths or showers to five to 10 minutes and use warm, not hot, water. 2. 2. Question When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: o A. Provides an opportunity for skin assessment. o B. Avoids undue strain on the nurse. o C. Increases venous blood return. o D. Causes vasoconstriction and increases circulation. Incorrect Correct Answer: C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. o Option A: The nurse can assess the patient’s condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. o Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). o Option D: It improves circulation but does not result in vasoconstriction. Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity. 3. 3. Question Vivid dreaming occurs in which stage of sleep? o A. Stage I non-REM o B. Rapid eye movement (REM) stage o C. Stage II non-REM o D. Delta stage Incorrect Correct Answer: B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour. o Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle. o Option C: This stage represents deeper sleep the heart rate and body temperature drop. It is characterized by the presence of sleep spindles, K-complexes, or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes show a transition into a deeper sleep. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep. o Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep. This is considered the deepest stage of sleep and is characterized by a much slower frequency with high amplitude signals known as delta waves. This stage is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. This is the stage when the body repairs and regrows its tissues, builds bone and muscle, and strengthens the immune system. 4. 4. Question The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is: o A. Flurazepam o B. Temazepam o C. Methotrimeprazine o D. Tryptophan Incorrect Correct Answer: D. Tryptophan Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter). o Option A: Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. o Option B: Temazepam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Temazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. o Option C: Levomepromazine (also known as methotrimeprazine) is used to treat severe mental/mood disorders (such as schizophrenia, bipolar disorder). It works by helping to restore certain natural substances in the brain. Levomepromazine belongs to a class of drugs known as phenothiazines. It can help the client to think clearly and take part in everyday life. It is also used to treat anxiety disorders, a certain sleep problem (insomnia), nausea/vomiting, and pain. This medication has calming, relaxing, and pain-relieving effects. 5. 5. Question Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: o A. Have the patient take a 30- to 60-minute nap in the afternoon. o B. Turn on the television in the patient’s room. o C. Provide quiet music and interesting reading material. o D. Massage the patient’s back with long strokes. Incorrect Correct Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon. Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep. o Option B: For patients in the hospital, factors that can prevent sound sleep include staff noise during a shift, telephones and call lights, doors, paging systems, and even carts wheeled through corridors. Safety and comfort can be promoted by raising side rails, placing the bed in a low position, and using night-lights. o Option C: For individuals who are unable to sleep, they must get out of bed and spend some time in another room. There, they can start some relaxing activities like reading and listening to soft music. They should continue the activity till they feel drowsy. o Option D: Rituals can be supported in institutionalized patients by assisting them with a hand and face wash, massage, pillow plumping, and even talking about today’s accomplishments and enjoyable events. These can promote relaxation and peace of mind. 6. 6. Question Restraints can be used for all of the following purposes except to: o A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. o B. Prevent a patient from falling out of bed or a chair. o C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. o D. Prevent a patient from becoming confused or disoriented. Incorrect Correct Answer: D. Prevent a patient from becoming confused or disoriented. By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient’s movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. The other choices are valid reasons for using restraints. o Option A: Sometimes hospital patients who are confused need restraints so that they do not remove catheters and tubes that give them medicine and fluids. A nurse who has special training in using restraints can begin to use them. A doctor or another provider must also be told restraints are being used. The doctor or other provider must then sign a form to allow the continued use of restraints. o Option B: Restraints may be used to keep a person in proper position and prevent movement or falling during surgery or while on a stretcher. Patients who are restrained also need to have their blood flow checked to make sure the restraints are not cutting off their blood flow. They also need to be watched carefully so that the restraints can be removed as soon as the situation is safe. o Option C: Restraints can also be used to control or prevent harmful behavior or get out of bed, fall, and hurt themselves. Restraints should not cause harm or be used as punishment. Health care providers should first try other methods to control a patient and ensure safety. Restraints should be used only as a last choice. 7. 7. Question Which of the following is the nurse’s legal responsibility when applying restraints? o A. Document the patient’s behavior. o B. Document the type of restraint used. o C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others. o D. All of the above. Incorrect Correct Answer: D. All of the above When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints. o Option A: Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient’s family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints. o Option B: There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient’s movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient’s mobility. o Option C: With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient’s family, substitute decision-makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful. 8. 8. Question Kubler-Ross’s five successive stages of death and dying are: o A. Anger, bargaining, denial, depression, acceptance o B. Denial, anger, depression, bargaining, acceptance o C. Denial, anger, bargaining, depression acceptance o D. Bargaining, denial, anger, depression, acceptance Incorrect Correct Answer: C. Denial, anger, bargaining, depression acceptance Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance. o Option A: Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. Patients may directly deny the diagnosis, attribute it to faulty tests or an unqualified physician, or simply avoid the topic in conversation. o Option B: Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice. o Option D: Bargaining typically manifests as patients seek some measure of control over their illness. The negotiation could be verbalized or internal and could be medical, social, or religious. The patients’ proffered bargains could be rational, such as a commitment to adhere to treatment recommendations or accept help from their caregivers, or could represent more magical thinking, such as with efforts to appease misattributed guilt they may feel is responsible for their diagnosis. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may choose to focus on enjoying the time they have left and reflecting on their memories. 9. 9. Question A terminally ill patient usually experiences all of the following feelings during the anger stage except: o A. Rage o B. Envy o C. Numbness o D. Resentment Incorrect Correct Answer: C. Numbness Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages. o Option A: The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?” Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice. o Option B: Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel “normal” again. o Option D: The anger may also be generalized and undirected, manifesting as a shorter temper or a loss of patience. Recognizing anger as a natural response can help health care providers and loved-ones to tolerate what might otherwise feel like hurtful accusations, though they must take care not to disregard criticism that may be warranted by attributing them solely to an emotional stage. [Show Less]
Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 6 | 75 Questions 1. 1. Question The nurse is caring for an elderly woman who has had a fractured... [Show More] hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client? o A. Arranging for the wheelchair o B. Asking her family to visit o C. Assisting her to sit out of bed in a chair qid o D. Encouraging the use of an overhead trapeze Incorrect Correct Answer: D. Encouraging the use of an overhead trapeze. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Facilitates movement during hygiene or skincare and linen changes; reduces the discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed. o Option A: Sitting in a wheelchair would require too great hip flexion initially. Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. Reduces the risk of flexion contracture of the hip. o Option B: Asking her family to visit would not facilitate the resumption of activities. Provide footboard, wrist splints, trochanter, or hand rolls as appropriate. Useful in maintaining a functional position of extremities, hands, and feet, and preventing complications (contractures, foot drop). o Option C: Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker. Encourage the use of isometric exercises starting with the unaffected limb. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present. 2. 2. Question Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding? o A. Measure intake and output o B. Check albumin level o C. Monitor glucose levels o D. Increase enteral feeding Incorrect Correct Answer: A. Measure intake and output It is important to measure intake and output, which should be equal. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance. A urinary catheter is inserted to assess the adequacy of renal perfusion. The kidney requires 20% to 25% of cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion or intravascular volume. o Option B: Osmotherapy aims to increase the osmolality of the intravascular space, which in turn helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to decrease cerebral edema, transiently increase intravascular volume, and improve cerebral blood flow. o Option C: Low peripheral oxygen saturation values or low arterial blood oxygen values (as shown by arterial blood gas testing) should be avoided. Maintaining adequate brain tissue oxygenation seems to improve patient outcomes. o Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis or VAP). 3. 3. Question The pathological process causing esophageal varices is/are: o A. Ascites and edema o B. Systemic hypertension o C. Portal hypertension o D. Dilated veins and varicosities Incorrect Correct Answer: C. Portal hypertension Esophageal varices result from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will backflow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids. o Option A: Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. Normal portal pressure is between 5-10 mmHg but in the presence of portal obstruction, the pressure may be as high as 15-20 mmHg. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and the right side of the heart results in retrograde flow and elevated pressure. o Option B: Esophageal varices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. They form due to portal hypertension, which commonly is a result of cirrhosis, resistance to portal blood flow, and increased portal venous blood inflow. o Option D: Intrahepatic vasoconstriction due to decreased nitric oxide production, and increased release of endothelin-1 (ET-1), angiotensinogen, and eicosanoids. Increased portal flow is caused by hyperdynamic circulation due to splanchnic arterial vasodilation through mediators such as nitric oxide, prostacyclin, and TNF. 4. 4. Question Which of the following interventions will help lessen the effect of GERD (acid reflux)? o A. Elevate the head of the bed on 4-6 inch blocks. o B. Lie down after eating. o C. Increase fluid intake just before bedtime. o D. Wear a girdle. Incorrect Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks. Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps control reflux and causes less irritation from reflux action into the esophagus. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure. o Option B: Avoid placing the patient in a supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by preventing the gastric acid to flow back into the esophagus. o Option C: Instruct patient regarding eating small amounts of bland food followed by a small amount of water. Instruct to remain in an upright position at least 1–2 hours after meals, and to avoid eating within 2–4 hours of bedtime. Gravity helps control reflux and causes less irritation from reflux action into the esophagus. o Option D: Instruct the patient to avoid bending over, coughing, straining at defecations, and other activities that increase reflux. Promotes comfort by the decrease in intra-abdominal pressure, which reduces the reflux of gastric contents. 5. 5. Question The main benefit of therapeutic massages is: o A. To help a person with swollen legs to decrease fluid retention. o B. To help a person with duodenal ulcers feel better. o C. To help damaged tissue in a diabetic to heal. o D. To improve circulation and muscle tone. Incorrect Correct Answer: D. To improve circulation and muscle tone. Particularly in elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. Damaged or strained muscle fibers release inflammatory chemicals to aid the healing process, but these chemicals cause significant pain and discomfort in the process. At least one study, which looked at the effects of massage on post-exercise tissue inflammation, suggests that even 10 minutes of massage can reduce signs of inflammation and improve cell processes, thereby promoting healing, with effects lasting several hours after the massage. o Option A: Massage only the hands, feet, or scalp of patients with sepsis, fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis. o Option B: When patients have fragile skin, or the potential for skin breakdown, apply only light pressure, using enough lotion or oil to minimize friction. For patients with a previous injury, chronic pain, or scar tissue, frequently ask them how the massage feels, and adjust both pressure and massage technique to the patients’ preferences. o Option C: A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot. Although massage is associated with few adverse effects, nurses should be careful to avoid areas near open wounds, any stage of pressure ulcer, reddened or swollen areas, rashes, incisions, thromboses, iv lines, drains, shunts, and tubes. 6. 6. Question Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)? o A. Lettuce o B. Eggs o C. Chocolate o D. Butterscotch Incorrect Correct Answer: C. Chocolate Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a surge of serotonin. This surge can cause the esophageal sphincter to relax and gastric contents to rise. Caffeine and theobromine in chocolate may also trigger acid reflux. All of the other foods do not affect LES pressure. o Option A: Vegetables are naturally low in fat and sugar, and they help reduce stomach acid. Good options include green beans, broccoli, asparagus, cauliflower, leafy greens, potatoes, and cucumbers. o Option B: Egg whites are a good option. Stay away from egg yolks, though, which are high in fat and may trigger reflux symptoms. Reflux symptoms may result from stomach acid touching the esophagus and causing irritation and pain. o Option D: The foods the patient eats affect the amount of acid the stomach produces. Eating the right kinds of food is key to controlling acid reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil. Reduce the intake of saturated fats and trans fats and replace them with these healthier unsaturated fats. 7. 7. Question Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)? o A. Withhold medications while the TPN is infusing. o B. Change TPN solution every 24 hours. o C. Flush the TPN line with water prior to initiating nutritional support. o D. Keep the client on complete bed rest during TPN therapy. Incorrect Correct Answer: B. Change TPN solution every 24 hours. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to the hypertonicity of the solution. Because the central venous catheter needs to remain in place for a long time, a strict sterile technique must be used during the insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques. o Option A: Medication therapy can continue during TPN therapy. Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often. o Option C: Flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skincare around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates. o Option D: However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest. Place the client in a semi-Fowler’s or high-Fowler’s position. Maintaining the head of the bed elevated will promote ease in breathing. This position also allows the pooling of fluid in the bases and for gas exchange to be more available to the lung tissue. 8. 8. Question Which of the following should be included in a plan of care for a client who is lactose intolerant? o A. Remove all dairy products from the diet. o B. Frozen yogurt can be included in the diet. o C. Drink small amounts of milk on an empty stomach. o D. Spread out selection of dairy products throughout the day. Incorrect Correct Answer: B. Frozen yogurt can be included in the diet. Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Some people who are lactose-intolerant can eat some kinds of yogurt without problems, especially yogurt with live cultures. o Option A: Elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Be sure to get enough calcium in the diet, especially if the client avoids milk products completely. To get enough calcium, the client would need to eat calcium-rich foods as often as someone would drink milk. Calcium is very important because it keeps bones strong and reduces the risk of osteoporosis. o Option C: Drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Limit the amount of milk and milk products in the diet. Try to drink 1 glass of milk each day. Drink small amounts several times a day. All types of milk contain the same amount of lactose. Option D: Although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms. Eat or drink milk and milk products along with other foods. For some people, combining solid food (like cereal) with a dairy product (like milk) can reduce symptoms. [Show Less]
Fundamentals of Nursing NCLEX RN Practice Questions| 75 Questions 1. 1. Question The charge nurse asks the nursing assistive personnel (NAP) to give a ... [Show More] bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? o A. Bathe the patient's entire body using 8 to 10 washcloths. o B. Assist the patient to a chair and provide bathing supplies. o C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. o D. Assist the patient to the bathtub and provide a bath chair. Incorrect Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. o Option B: A bag bath is not given in a chair or in the tub. The bag bath is one alternative to the traditional bed bath used in some nursing homes. The bath is performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the door and windows to prevent cold drafts and wash hands with warm water before beginning. o Option C: Moisten the washcloths with water and put in a plastic bag with the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature of the clothes before touching a resident with them and be careful when you open the bag, as steam can burn. o Option D: Take the bag to the resident’s bedside. When you are not cleaning a body part, keep it covered. Only expose as much of the resident’s body as necessary to adequately clean him or her. Be especially sensitive to exposing genitals, buttocks, and breasts. Bathing can be an extremely stressful experience for residents, so try to make it as easy as possible. 2. 2. Question For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? o A. Cover the mattress with a sheepskin. o B. Keep the linens wrinkle free. o C. Separate the skin folds with towels. o D. Apply petrolatum barrier creams. Incorrect Correct Answer: C. Separate the skin folds with towels. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas. o Option A: Sheepskins are not recommended for use at all. Skin folds present a challenge in the management of patients who are morbidly obese. The weight from excess adipose tissue in skinfold areas can have an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development. o Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds. o Option D: Petrolatum barrier creams are used to minimize moisture caused by incontinence. Patient hydration should also be considered in the nutrition plan for the patients and the health of their skin. 3. 3. Question A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? o A. Fever o B. Intact skin o C. Inflammation o D. Lethargy Incorrect Correct Answer: B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. o Option A: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body’s defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Fever results from an actual resetting of the hypothalamus’s thermostat. The body raises its temperature to a higher level by moving (shunting) blood from the skin surface to the interior of the body, thus reducing heat loss. o Option C: Any injury, including an invasion by microorganisms, causes inflammation in the affected area. Inflammation, a complex reaction, results from many different conditions. During inflammation, the blood supply increases, helping carry immune cells to the affected area. Because of the increased blood flow, an infected area near the surface of the body becomes red and warm. The walls of blood vessels become more porous, allowing fluid and white blood cells to pass into the affected tissue. The increase in fluid causes the inflamed tissue to swell. The white blood cells attack the invading microorganisms and release substances that continue the process of inflammation. o Option D: Lethargy refers to a state of lacking energy. People who are experiencing fatigue or tiredness can also be said to be lethargic because of low energy. The same medical conditions that can lead to tiredness or fatigue can also lead to lethargy. 4. 4. Question A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? o A. A clean gown and gloves must be worn when in contact with the client. o B. Everyone who enters the room must wear a N-95 respirator mask. o C. All linen and trash must be marked as contaminated and send to biohazard waste. o D. Place the client in a room with a client with an upper respiratory infection. Incorrect Correct Answer: A. A clean gown and gloves must be worn when in contact with the client. A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. Visitors might also be asked to wear a gown and gloves. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. o Option B: A respirator mask is required only with airborne precautions, not contact precautions. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. o Option C: All linen must be double-bagged and clearly marked as contaminated. When leaving the room, healthcare providers and visitors remove their gown and gloves and clean their hands. o Option D: The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. 5. 5. Question A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: o A. Admitted with unstable diabetes mellitus. o B. Who underwent surgical repair of a perforated bowel. o C. With a stage 3 sacral pressure ulcer. o D. Admitted with a urinary tract infection. Incorrect Correct Answer: A. Admitted with unstable diabetes mellitus. The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Protective Isolation aims to protect an immunocompromised patient who is at high risk of acquiring micro-organisms from either the environment or from other patients, staff, or visitors. o Option B: Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. Patients should remain in isolation whilst they remain symptomatic; a risk assessment should be undertaken to ascertain if and when isolation precautions can be relaxed. o Option C: A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer. Patient’s requiring protective isolation should be nursed in a single room. Where possible this room should have an ante-room, positive pressure ventilation and Hepa filtered air. The room should have an en-suite and hand washing facilities and the doors(s) should be kept closed at all times. o Option D: A client in protective isolation should not be paired with a client who has a urinary tract infection. Many infections acquired by immunocompromised patients are endogenous infections (An infection caused by an infectious agent that is already present in the body but has previously been inapparent or dormant), however, the transmission of infection from other patients, staff, or the environment can be a risk and therefore extra precautions are required. 6. 6. Question A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique? o A. Remaining 1 foot away from non sterile areas. o B. Placing sterile items on the sterile field. o C. Avoiding the border of the sterile drape. o D. Reaching 1 foot over the sterile field. Incorrect Correct Answer: D. Reaching 1 foot over the sterile field. Reaching over the sterile field while wearing sterile garb breaks the sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from non-sterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. The principles of the Sterile Technique are applied in various ways. If the principle itself is understood, the applications of it become obvious. A strict aseptic technique is needed at all times in the Operating Room. o Option A: Sterile persons avoid leaning over an unsterile area; non-sterile persons avoid reaching over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field. o Option B: Persons who are sterile touch only sterile articles; persons who are not sterile touch only unsterile articles. If in doubt about the sterility of anything consider it not sterile. If a non-sterile person brushes close consider yourself contaminated. o Option C: Sterile persons keep contact with sterile areas to a minimum. Do not lean on the sterile tables or on the draped patient. Do not lean on the nurse’s mayo tray. 7. 7. Question Nurse Berta is facilitating a monthly mothers’ class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk? o A. IgA o B. IgE o C. IgG o D. IgM Incorrect Correct Answer: A. IgA Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA, particularly the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues. o Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a serum concentration of 0.00005 mg/mL. It protects against parasites and also binds to high-affinity receptors on mast cells and basophils causing allergic reactions. IgE is regarded as the most important host defense against different parasitic infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenal. o Option C: IgG2 forms an important host defense against bacteria that are encapsulated. IgG is the only immunoglobulin that crosses the placentae as its Fc portion binds to the receptors present on the surface of the placenta, protecting the neonate from infectious diseases. IgG is thus the most abundant antibody present in newborns. o Option D: IgM has a molecular weight of 970 Kd and an average serum concentration of 1.5 mg/ml. It is mainly produced in the primary immune response to infectious agents or antigens. It is a pentamer and activates the classical pathway of the complement system. IgM is regarded as a potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B and type A blood respectively) and a monomer of IgM is used as a B cell receptor (BCR). 8. 8. Question The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: o A. Transient flora from the skin o B. Resident flora from the skin o C. All microorganisms from the skin o D. Media for bacterial growth Incorrect Correct Answer: A. Transient flora from the skin There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed unnecessarily for these health issues o Option B: Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. o Option C: Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. o Option D: Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing. Handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 5 young children with respiratory infections like pneumonia. 9. 9. Question Which of the following incidents requires the nurse to complete an occurrence report? o A. Medication given 30 minutes after scheduled dose time. o B. Patient's dentures lost after transfer. o C. Worn electrical cord discovered on an IV infusion pump. o D. Prescription without the route of administration. Incorrect Correct Answer: B. Patient’s dentures lost after transfer You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. An incident report also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there’s no way to make these important decisions effectively. o Option A: A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. An incident report invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident. o Option C: The worn electrical cord should be taken out of use and reported to the biomedical department. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required. o Option D: The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary. The medical record is patient-focused, and facts pertinent to an unexpected incident will likely be left out. So if a claim were filed and the case proceeded to court, which sometimes occurs years after the event, you or anyone else involved might be hard-pressed to recreate the scene—especially if you consider it to be “minor” at the time. You may not be able to rely on memory alone, but you can count on the incident report to refresh your memory. [Show Less]
Fundamentals of Nursing NCLEX RN Practice Questions Q&A 2 1. 1. Question Which intervention is an example of primary prevention? o A. Administering ... [Show More] digoxin (Lanoxicaps) to a patient with heart failure. o B. Administering measles, mumps, and rubella immunization to an infant. o C. Obtaining a Papanicolaou smear to screen for cervical cancer. o D. Using occupational therapy to help a patient cope with arthritis. Incorrect Correct Answer: B. Administering measles, mumps, and rubella immunization to an infant. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future. o Option A: Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to prevent more severe problems developing. Here health educators such as Health Extension Practitioners can help individuals acquire the skills of detecting diseases in their early stages. o Option C: Obtaining a Papanicolau smear is a secondary prevention. Secondary prevention includes those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury. This should limit disability, impairment, or dependency and prevent more severe health problems developing in the future. o Option D: Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring. Tertiary prevention includes those preventive measures aimed at rehabilitation following significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability. 2. 2. Question The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first? o A. Auscultation o B. Inspection o C. Percussion o D. Palpation Incorrect Correct Answer: B. Inspection Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation. o Option A: The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance. o Option C: A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly). o Option D: The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation. 3. 3. Question Which statement regarding heart sounds is correct? o A. S1 and S2 sound equally loud over the entire cardiac area. o B. S1 and S2 sound fainter at the apex. o C. S1 and S2 sound fainter at the base. o D. S1 is loudest at the apex, and S2 is loudest at the base. Incorrect Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created. o Option A: The S1 heart sound is produced as the mitral and tricuspid valves close in systole. This structural and hemodynamic change creates vibrations that are audible at the chest wall. The mitral valve closing is the louder component of S1. It also occurs sooner because of the left ventricle contracts earlier in systole. o Option B: Changes in the intensity of S1 are more attributable to forces acting on the mitral valve. Such causes include a change in left ventricular contractility, mitral structure, or the PR interval. However, under normal resting conditions, the mitral and tricuspid sounds occur close enough together not to be discernible. The most common reasons for a split S1 are things that delay right ventricular contraction, like a right bundle branch block. o Option C: The S2 heart sound is produced with the closing of the aortic and pulmonic valves in diastole. The aortic valve closes sooner than the pulmonic valve, and it is the louder component of S2; this occurs because the pressures in the aorta are higher than the pulmonary artery. 4. 4. Question The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process? o A. Assessment o B. Nursing diagnosis o C. Planning o D. Evaluation Incorrect Correct Answer: B. Nursing diagnosis The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community. o Option A: During the assessment step, the nurse systematically collects data about the patient or family. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. o Option C: During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. o Option D: During the evaluation step, the nurse determines the effectiveness of the plan of care. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. 5. 5. Question A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: o A. Fresh, green vegetables o B. Bananas and oranges o C. Lean red meat o D. Creamed corn Incorrect Correct Answer: B. Bananas and oranges Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium. o Option A: GLVs are considered as natural caches of nutrients for human beings as they are a rich source of vitamins, such as ascorbic acid, folic acid, tocopherols, ?-carotene, and riboflavin, as well as minerals such as iron, calcium, and phosphorous. o Option C: Lean red meat is an excellent source of high biological value protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a source of long?chain omega?3 polyunsaturated fats, riboflavin, pantothenic acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat and sodium. o Option D: Corn has several health benefits. Because of the high fiber content, it can aid with digestion. It also contains valuable B vitamins, which are important to your overall health. Corn also provides our bodies with essential minerals such as zinc, magnesium, copper, iron, and manganese. 6. 6. Question The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol? o A. Lethal arrhythmias o B. Malignant hypertension o C. Status epilepticus o D. Bone marrow suppression Incorrect Correct Answer: D. Bone marrow suppression The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus. o Option A: Chloramphenicol is associated with severe hematological side effects when administered systemically. Since 1982, chloramphenicol has reportedly caused fatal aplastic anemia, with possible increased risk when taken together with cimetidine. This adverse side effect can occur even with the topical administration of the drug, which is most likely due to the systemic absorption of the drug after topical application. o Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other side effects of chloramphenicol include ototoxicity with the use of topical ear drops, gastrointestinal reactions such as oesophagitis with oral use, neurotoxicity, and severe metabolic acidosis. o Option C: Optic neuritis is the most commonly associated neurotoxic complication that can arise from chloramphenicol use. This adverse effect usually takes more than six weeks to manifest, presenting with either acute or subacute vision loss, with possible fundal changes. It may also present with peripheral neuropathy, which may present as numbness or tingling. If optic neuropathy occurs, the drug should be withdrawn immediately, which will usually lead to partial or complete recovery of vision. 7. 7. Question A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? o A. Impaired gas exchanges related to increased blood flow. o B. Fluid volume excess related to peripheral vascular disease. o C. Risk for injury related to edema. o D. Altered peripheral tissue perfusion related to venous congestion. Incorrect Correct Answer: D. Altered peripheral tissue perfusion related to venous congestion. Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. o Option A: Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is commonest in the lower limb below the knee and starts at low-flow sites, such as the soleal sinuses, behind venous valve pockets. o Option B: Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Nurses need to educate the patients on the importance of ambulation, being compliant with compression stockings, and taking the prescribed anticoagulation medications. o Option C: Option C may be warranted but is secondary to altered tissue perfusion. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis. 8. 8. Question When positioned properly, the tip of a central venous catheter should lie in the: o A. Superior vena cava o B. Basilica vein o C. Jugular vein o D. Subclavian vein Incorrect Correct Answer: A. Superior vena cava When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters. o Option B: There are three main access sites for the placement of central venous catheters. The internal jugular vein, common femoral vein, and subclavian veins are the preferred sites for temporary central venous catheter placement. Additionally, for mid-term and long-term central venous access, the basilic and brachial veins are utilized for peripherally inserted central catheters (PICCs). o Option C: The internal jugular vein (IJ) is often chosen for its reliable anatomy, accessibility, low complication rates, and the ability to employ ultrasound guidance during the procedure. The individual clinical scenario may dictate laterality in some cases (such as with trauma, head and neck cancer, or the presence of other invasive devices or catheters), but all things being equal, many physicians prefer the right IJ. As compared to the left, the right IJ forms a more direct path to the superior vena cava (SVC) and right atrium. It is also wider in diameter and more superficial, thus presumably easier to cannulated. o Option D: The subclavian vein site has the advantage of low rates of both infectious and thrombotic complications. Additionally, the SC site is accessible in trauma, when a cervical collar negates the choice of the IJ. However, disadvantages include a higher relative risk of pneumothorax, less accessibility to use ultrasound for CVC placement, and the non-compressible location posterior to the clavicle. 9. 9. Question Nurse Nikki is revising a client’s care plan. During which step of the nursing process does such revision take place? o A. Assessment o B. Planning o C. Implementation o D. Evaluation Incorrect Correct Answer: D. Evaluation During the evaluation step of the nursing process, the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. o Option A: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. o Option B: The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. o Option C: Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards. 10. 10. Question A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” Which statement would be the nurse’s best response? o A. “The contraction phase of wound healing can take 2 to 3 years.” o B. “Wound healing is very individual but within 4 months the scar should fade. o C. “With your history and the type of location of the injury, it’s hard to say.” o D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.” Incorrect Correct Answer: C. “With your history and the type of location of the injury, it’s hard to say.” Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. There is no doubt that diabetes plays a detrimental role in wound healing. It does so by affecting the wound healing process at multiple steps. Wound hypoxia, through a combination of impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia, is a major driver of chronic diabetic wounds. o Option A: Ischemia can lead to prolonged inflammation, which increases the levels of oxygen radicals, leading to further tissue injury. Elevated levels of matrix metalloproteases in chronic diabetic wounds, sometimes up to 50-100 times higher than acute wounds, cause tissue destruction and prevent normal repair processes from taking place. Furthermore, diabetes is associated with impaired immunity, with critical defects occurring at multiple points within the immune system cascade of the wound healing process. o Option B: To further complicate matters, these wounds have defects in angiogenesis and neovascularization. Normally, wound hypoxia stimulates mobilization of endothelial progenitor cells via vascular endothelial growth factor (VEGF). In diabetic wounds, there are aberrant levels of VEGF and other angiogenic factors such as angiopoietin-1 and angiopoietin-2 that lead to dysangiogenesis. o Option D: Diabetic neuropathy may also play a role in poor wound healing. Lower levels of neuropeptides, as well as reduced leukocyte infiltration as a result of sensory denervation, have been shown to impair wound healing. When combined, all these diverse factors play a role in the formation and propagation of chronic, debilitating wounds in patients with diabetes. [Show Less]
Fundamentals of Nursing NCLEX RN Practice Questions Q&A 1. 1. Question The most important nursing intervention to correct skin dryness is: o A. Consul... [Show More] t the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. o B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. o C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. o D. Avoid bathing the patient until the condition is remedied, and notify the physician. Incorrect Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing. o Option B: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin. o Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol. o Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from the skin. Limit baths or showers to five to 10 minutes and use warm, not hot, water. 2. 2. Question When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: o A. Provides an opportunity for skin assessment. o B. Avoids undue strain on the nurse. o C. Increases venous blood return. o D. Causes vasoconstriction and increases circulation. Incorrect Correct Answer: C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. o Option A: The nurse can assess the patient’s condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. o Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). o Option D: It improves circulation but does not result in vasoconstriction. Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity. 3. 3. Question Vivid dreaming occurs in which stage of sleep? o A. Stage I non-REM o B. Rapid eye movement (REM) stage o C. Stage II non-REM o D. Delta stage Incorrect Correct Answer: B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour. o Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle. o Option C: This stage represents deeper sleep the heart rate and body temperature drop. It is characterized by the presence of sleep spindles, K-complexes, or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes show a transition into a deeper sleep. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep. o Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep. This is considered the deepest stage of sleep and is characterized by a much slower frequency with high amplitude signals known as delta waves. This stage is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. This is the stage when the body repairs and regrows its tissues, builds bone and muscle, and strengthens the immune system. 4. 4. Question The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is: o A. Flurazepam o B. Temazepam o C. Methotrimeprazine o D. Tryptophan Incorrect Correct Answer: D. Tryptophan Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter). o Option A: Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. o Option B: Temazepam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Temazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. o Option C: Levomepromazine (also known as methotrimeprazine) is used to treat severe mental/mood disorders (such as schizophrenia, bipolar disorder). It works by helping to restore certain natural substances in the brain. Levomepromazine belongs to a class of drugs known as phenothiazines. It can help the client to think clearly and take part in everyday life. It is also used to treat anxiety disorders, a certain sleep problem (insomnia), nausea/vomiting, and pain. This medication has calming, relaxing, and pain-relieving effects. 5. 5. Question Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: o A. Have the patient take a 30- to 60-minute nap in the afternoon. o B. Turn on the television in the patient’s room. o C. Provide quiet music and interesting reading material. o D. Massage the patient’s back with long strokes. Incorrect Correct Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon. Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep. o Option B: For patients in the hospital, factors that can prevent sound sleep include staff noise during a shift, telephones and call lights, doors, paging systems, and even carts wheeled through corridors. Safety and comfort can be promoted by raising side rails, placing the bed in a low position, and using night-lights. o Option C: For individuals who are unable to sleep, they must get out of bed and spend some time in another room. There, they can start some relaxing activities like reading and listening to soft music. They should continue the activity till they feel drowsy. o Option D: Rituals can be supported in institutionalized patients by assisting them with a hand and face wash, massage, pillow plumping, and even talking about today’s accomplishments and enjoyable events. These can promote relaxation and peace of mind. 6. 6. Question Restraints can be used for all of the following purposes except to: o A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. o B. Prevent a patient from falling out of bed or a chair. o C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. o D. Prevent a patient from becoming confused or disoriented. Incorrect Correct Answer: D. Prevent a patient from becoming confused or disoriented. By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient’s movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. The other choices are valid reasons for using restraints. o Option A: Sometimes hospital patients who are confused need restraints so that they do not remove catheters and tubes that give them medicine and fluids. A nurse who has special training in using restraints can begin to use them. A doctor or another provider must also be told restraints are being used. The doctor or other provider must then sign a form to allow the continued use of restraints. o Option B: Restraints may be used to keep a person in proper position and prevent movement or falling during surgery or while on a stretcher. Patients who are restrained also need to have their blood flow checked to make sure the restraints are not cutting off their blood flow. They also need to be watched carefully so that the restraints can be removed as soon as the situation is safe. o Option C: Restraints can also be used to control or prevent harmful behavior or get out of bed, fall, and hurt themselves. Restraints should not cause harm or be used as punishment. Health care providers should first try other methods to control a patient and ensure safety. Restraints should be used only as a last choice. 7. 7. Question Which of the following is the nurse’s legal responsibility when applying restraints? o A. Document the patient’s behavior. o B. Document the type of restraint used. o C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others. o D. All of the above. Incorrect Correct Answer: D. All of the above When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints. o Option A: Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient’s family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints. o Option B: There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient’s movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient’s mobility. o Option C: With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient’s family, substitute decision-makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful. 8. 8. Question Kubler-Ross’s five successive stages of death and dying are: o A. Anger, bargaining, denial, depression, acceptance o B. Denial, anger, depression, bargaining, acceptance o C. Denial, anger, bargaining, depression acceptance o D. Bargaining, denial, anger, depression, acceptance Incorrect Correct Answer: C. Denial, anger, bargaining, depression acceptance Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance. o Option A: Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. Patients may directly deny the diagnosis, attribute it to faulty tests or an unqualified physician, or simply avoid the topic in conversation. o Option B: Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice. o Option D: Bargaining typically manifests as patients seek some measure of control over their illness. The negotiation could be verbalized or internal and could be medical, social, or religious. The patients’ proffered bargains could be rational, such as a commitment to adhere to treatment recommendations or accept help from their caregivers, or could represent more magical thinking, such as with efforts to appease misattributed guilt they may feel is responsible for their diagnosis. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may choose to focus on enjoying the time they have left and reflecting on their memories. 9. 9. Question A terminally ill patient usually experiences all of the following feelings during the anger stage except: o A. Rage o B. Envy o C. Numbness o D. Resentment Incorrect Correct Answer: C. Numbness Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages. o Option A: The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?” Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice. o Option B: Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel “normal” again. o Option D: The anger may also be generalized and undirected, manifesting as a shorter temper or a loss of patience. Recognizing anger as a natural response can help health care providers and loved-ones to tolerate what might otherwise feel like hurtful accusations, though they must take care not to disregard criticism that may be warranted by attributing them solely to an emotional stage. 10. 10. Question Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal? o A. Taking psychology courses related to gerontology. o B. Reading books and other literature on the subject of thanatology. o C. Reflecting on the significance of death. o D. Reviewing varying cultural beliefs and practices related to death. Incorrect Correct Answer: C. Reflecting on the significance of death According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured. Thanatology is the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more. o Option A: Professionals in a wide range of disciplines use thanatology to inform their work, from doctors and coroners to hospice workers and grief counselors. There also are thanatology specialists who focus on a specific aspect of the dying process or work directly with people facing their own death or that of loved ones. o Option B: A wide variety of professionals incorporate thanatology into their work. How they do so depends on what they need to know about the dying process. For example, a medical examiner, coroner, doctor, nurse, or other medical practitioners might study thanatology to better understand the physical process of death—what happens to the body during death as well as immediately after. o Option D: Thanatology also examines attitudes toward death, the meaning and behaviors of bereavement and grief, and the moral and ethical questions of euthanasia, organ transplants, and life support. [Show Less]
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