NUR_212_PQ2, Questions and Answers
What is the goal of family therapy as a component of treatment for a patient who has schizophrenia?
Assess family
... [Show More] history of schizophrenia. Increase family's caregiving ability.
Reduce family's stress level.
Teach family case management skills.
1) This is not the appropriate goal.
2) See 1).
*3) Family stress is a very real need for the family with a member who has schizophrenia. Reducing the family's stress level is the priority goal.
4) See 1).
Alterations in Mental Health
Which statement made by a patient indicates a readiness to learn, regarding reality perception? "I am not taking that medicine. You want to hurt me."
"There's nothing wrong with me. I've just been under a lot of stress." "I am not here for a mental illness; I have blood clots in my legs."
"I think maybe those voices I heard aren't real. How can I make them go away?"
1) This comment indicates a lack of trust.
2) This comment demonstrates unrealistic self-perception.
3) This comment reflects a distortion of reality.
*4) The patient recognizes reality distortions and seeks to learn strategies to manage symptoms. Alterations in Mental Health
Which statement made by a patient is an example of delusions of grandeur? "The FBI has bugged my room and intends to kill me."
"I just discovered a cure for cancer."
"Someone is trying to get a message to me through this television show." "I'm not really here. I'm already dead."
1) This is an example of delusions of persecution.
*2) This is an example of delusions of grandeur.
3) This is an example of delusions of reference.
4) This is an example of a nihilistic delusion.
Alterations in Mental Health
A patient presents with a history of borderline personality disorder. The patient exhibits alternating clinging and distancing behaviors, staff splitting, and manipulation. Based on this information, which is the most appropriate nursing diagnosis label?
Disturbed Personal Identity Impaired Social Interaction
Risk for Other-Directed Violence Risk for Self-Mutilation
1) Disturbed Personal Identity includes feelings of depersonalization and derealization.
*2) Alternating clinging and distancing behaviors, staff splitting, and manipulation are consistent with a nursing diagnosis label of Impaired Social Interaction.
3) Risk for Other-Directed Violence may include threatening body language, a history of childhood abuse, and transient psychotic symptomotology.
4) Risk for Self-Mutilation includes a history of self-injurious behavior, impulsivity, and an irresistible urge to damage self.
Alterations in Mental Health
A patient experiencing extreme delusions does not respond to de-escalation techniques or to medication prescribed as needed. After assaulting several staff members and breaking furniture in an attempt to leave the hospital, the patient is placed in restraints and seclusion. What is the RN's priority at this time?
Notify the patient's family that the patient has been placed in restraints. Alert the nursing supervisor about the staff injuries and property damage.
Call the health care provider to evaluate the patient in person within the hour.
Thoroughly document the facts in the incident leading up to why the patient required restraints and seclusion.
1) See 3).
2) See 3).
*3) The Joint Commission (TJC) requires that a health care provider or other licensed independent practitioner evaluate the patient within 1 hour of being placed in restraints and seclusion.
4) See 3).
Alterations in Mental Health
A patient with obsessive-compulsive disorder (OCD) has a nursing diagnosis label of Anxiety. Which patient outcomes are most appropriate for the RN to expect in caring for this patient?
(Select all that apply.)
Decrease the amount of time focusing on symptoms. Maintain an adequate state of nutrition.
Avoid harming self.
Use support systems.
Identify personal worry triggers.
*1) Goals for a patient with anxiety include identifying situations that trigger obsessive symptoms and allowing support of symptoms.
2) There is no evidence that the patient has nutritional difficulties.
3) Persons with OCD and anxiety are not likely to harm self.
*4) See 1).
*5) See 1).
Alterations in Mental Health
During a medication class for family members of patients with bipolar disorder, the nurse discusses common side effects of lithium. Which side effects would be included in the instruction?
(Select all that apply.)
Drinking a lot of water Frequent urination Constipation
Lethargy Metallic taste
*1) Lithium may cause excessive thirst, due to loss of water and sodium.
*2) Polydipsia and polyuria are among the side effects of lithium.
3) Constipation is not a common side effect of lithium.
4) This is a symptom of lithium toxicity, but not a common side effect.
*5) Metallic taste is a common side effect of lithium therapy. Alterations in Mental Health
An RN is giving a patient a dose of the antipsychotic medication haloperidol (Haldol). This medication is most effective in modifying which symptom of schizophrenia?
Flat affect
Social withdrawal
Delusions of persecution Lack of motivation
1) A flat affect is a negative symptom of schizophrenia that is more effectively treated by the newer atypical antipsychotics such as clozapine, risperidone, and olanzapine.
2) Social withdrawal is a negative symptom of schizophrenia that is more effectively treated by the newer atypical antipsychotics such as clozapine, risperidone, and olanzapine.
*3) Haloperidol (Haldol) is a typical or traditional antipsychotic that targets the positive symptoms of schizophrenia such as hallucinations, delusions, disordered thinking, and paranoia.
4) Lack of motivation is a negative symptom of schizophrenia that is more effectively treated by the newer atypical antipsychotics such as clozapine, risperidone, and olanzapine.
Alterations in Mental Health
Which of the following statements made by a patient who has been hospitalized with major depressive disorder and been on sertraline (Zoloft) for 2 months, would need to be passed on in the change of shift report?
"I can stop taking the Zoloft anytime I want to."
"I got an upset stomach when I first started taking the Zoloft."
"I had to stop taking the St. John's wort before I started on Zoloft." "Zoloft can cause sexual side effects."
*1) The patient may not understand that it is not a good idea to stop taking medication suddenly and this will have to be addressed. SSRIs have a discontinuation syndrome associated with sudden cessation. While it is not life threatening, it is uncomfortable.
2) GI upset and headaches are the most common side effects early in administration.
3) Serotonin syndrome can be triggered by this combination.
4) Zoloft can cause prolonged erection in men, which requires immediate treatment. It can cause anorgasmia in women, which may require future medication treatment.
Alterations in Mental Health
Which mental health disorder is most closely associated with excess weight or obesity, which can lead to heart disease and diabetes?
Attention-deficit/Hyperactivity disorder Autism spectrum disorder
Major depressive disorder Social anxiety disorder
1) ADHD is more closely associated with accidents and injuries.
2) Complications from ASD can include sensory problems, withdrawal, or aggression.
*3) Major depressive disorder is associated with excess weight or obesity, which can lead to heart disease and diabetes.
4) Potential complications from social anxiety disorder may include low academic and employment achievement.
Disorders of Identity, Self-Esteem and Coping
An RN is caring for a patient who presents in the emergency department (ED) for treatment of injuries sustained as a result of suspected battering by a domestic partner. The RN recognizes which of the following interventions will require collaboration with other health care professionals?
Providing immediate emotional support Completing an initial physical assessment Ensuring that the patient has a safe place to stay Asking the patient if they are in any kind of danger
1) Providing initial emotional support is an independent nursing function.
2) The RN may complete an initial physical assessment independently, including vital signs and observing for any injuries that require immediate attention.
*3) The RN can assure the patient of his/her immediate safety, but will need to collaborate with other health care professionals in the event that the patient needs a safe place to stay.
4) Nurses independently screen all patients for the possibility that they are in danger. Disorders of Identity, Self-Esteem and Coping
A psychiatric RN identifies sexual performance as a concern of several older male patients. What is the most appropriate action by the RN?
Ask the unit provider to order a urology expert to speak with any patient who is interested in consultation.
Place printed materials about sexual issues and treatment in the dayroom so that any interested patients may read them.
Meet one-on-one with patients who have expressed anxiety about sexual issues to further assess their needs and provide individualized sex education.
Develop an education program for staff to prepare them to discuss with patients how smoking cessation and exercise can reduce sexual dysfunction.
1) Discussing patient concerns related to sexuality is within the scope of nursing practice and does not require referral to another professional.
2) Printed materials can be a useful supplement, but they are not a substitute for talking with professional staff. Sexually-related materials may not be appropriate for all patients (for example, an antisocial patient) and putting them in the day room could cause disruption on the unit.
3) This would only be effective with a small number of patients. Instead, preparing other staff to also counsel patients would help more patients.
*4) This response would improve the ability of staff to deliver better patient-centered care and meet the QSEN core competencies of using EBP and supporting quality-improvement initiatives. Disorders of Identity, Self-Esteem and Coping
A patient with a long history of violence towards other people is admitted to a psychiatric unit. Which instruction would be most helpful for the RN to give to the LPN/LVN who has just begun working on the unit?
"Please observe the patient for any signs of increased hostility."
"Let me know if the patient has any significant changes in behavior, as this might indicate the patient will become physically aggressive."
"If the patient starts to swear or threatens anyone, come and get me immediately, as this kind of behavior often leads to aggression."
"Acting out behavior is usually difficult to predict and it would be normal for you to feel anxious working here."
1) This response is too vague; the nurse should explain clearly what is expected of the LPN.
2) The nurse is not telling the LPN what specific behaviors to look for.
*3) The nurse is describing "prodromal syndrome." Swearing and threatening others are both classic indicators of potential violence.
4) Acting out behavior is not hard to predict. Telling the nurse it is normal to feel anxious without providing more direction is not helpful.
Disorders of Identity, Self-Esteem and Coping
After listening to a shift report, an RN must decide which patient to assess first. Which patient should be the RN's priority for assessment?
A patient who is scheduled for a breast biopsy the next day and has questions about the procedure
A patient who reports feeling sad all day after being newly diagnosed with diabetes mellitus (type 2)
A patient who is pacing in front of the nurses' station, while cursing softly
A patient whose lithium dose was increased that morning, from 300 mg twice a day to 600 mg twice a day
1) See 3).
2) See 3).
*3) Pacing and cursing are "prodromal syndrome" behaviors, indicating an increased imminent risk of violence towards self or others.
4) See 3).
Disorders of Identity, Self-Esteem and Coping
After being held hostage in a robbery, a bank employee tells the occupational health RN about having developed post-traumatic stress disorder (PTSD). Which statement made by the patient would support a diagnosis of PTSD?
"Every night I dream that the person is coming back to shoot me." "I stay up every night until I fall asleep watching television."
"I canâ t get to sleep unless I have beer before bed."
"Every morning I wake up at 5 in the morning and I cannot go back to sleep."
*1) Recurrent distressing dreams about the traumatic event are diagnostic criteria of PTSD.
2) Staying up watching television may cause drowsiness the next day, but in itself is not pathological.
3) Drinking alcohol before sleeping may actually interfere with sleep. One alcoholic drink a night is not on its own indicative of PTSD.
4) Early morning awakening is a possible symptom of depression rather than PTSD. Disorders of Identity, Self-Esteem and Coping
An RN is working with a patient with altered sexual function. Which rationale best supports the RN asking the patient to identify what they perceive to be the primary problem?
It will elicit information that is necessary to determine if the patient has a diagnosable condition. It will elicit information that is necessary to establish appropriate goals of care.
It will help in distinguishing between a physiological or psychological issue. It will assist in determining if the patient requires a licensed sex therapist.
1) The patient's perception of the problem is the focus of nursing care, regardless of whether or not the patient has a diagnosable condition.
*2) The patient's perception of the problem may differ from that of the RN's. Appropriate, patient-centered goals of care should be established around the patient's perception of the problem.
3) Whether or not the problem is physiological or psychological, the patient's perception of the problem is essential to identifying appropriate goals for care.
4) The primary reason for having the patient identify their perception of the problem is to provide patient-centered nursing care. Identifying the need for collaborative care is secondary. Disorders of Identity, Self-Esteem and Coping
An RN is planning care for a patient who has experienced a significant trauma. Which interventions require collaboration from other health professionals?
(Select all that apply.)
Providing support during flashbacks Identifying adaptive coping strategies Initiating prolonged exposure therapy Monitoring the effectiveness of medication Selecting appropriate therapeutic medication
1) Providing support during flashbacks is an independent nursing action.
2) Identifying adaptive coping strategies is an independent nursing action.
*3) Although RNs may assist practitioners with exposure therapy, the decision to initiate and carry out this activity requires collaboration from a paraprofessional with specialized expertise in this type of therapy.
4) RNs are responsible for monitoring the effectiveness of medication.
*5) Only licensed providers can select and prescribe medication.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders Which are desired outcomes for adult patients who are participating in a therapeutic group? (Select all that apply.)
Demonstrate an increased ability to make decisions. Provide support for members to effect changes.
Demonstrate increased interest in their environment. Show increased ability to interact with others.
Show increased ability to forgive themselves.
*1) Functions of therapeutic groups include emotional support and empowerment.
2) Therapeutic groups do not have effecting changes as one of their goals.
*3) See 1).
*4) See 1).
5) Self-forgiveness is associated with self-help groups, not therapeutic groups. Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
When teaching the family of a patient with Alzheimer's disease about rivastigmine (Exelon), what point would be important for the RN to include?
"This medication's side effects are tremors and increased sleep." "This medication may cause gastrointestinal upset and headache."
"This medication will reverse short-term memory loss and restore previous cognitive abilities." "The medication is an antipsychotic that reduces agitation associated with Alzheimer's disease."
1) These are side effects of a typical antipsychotic agent.
*2) The medication may cause GI upset and headache.
3) It is important that the family understands that short-term memory has been lost.
4) Aricept is a type cholinesterase inhibitor, not an antipsychotic agent.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
An RN reviews a mini-mental status exam (MMSE) indicating that the patient is alert and oriented to time and place, has delayed mental responses and motor activity without tremors or involuntary movements, steady gait, depressed mood, intact concentration, and mild forgetfulness. The RN knows these MMSE findings correspond with which diagnosis?
Alzheimer's disease Creutzfeldt-Jakob disease Pseudodementia
Vascular dementia
1) Findings include short term memory loss, confabulation, and disoriented to time and place.
2) This is a prion disease (Mad Cow) with findings that include myoclonus, ataxia, and involuntary movements.
*3) Findings include depressed mood, anergia, some forgetfulness, oriented to time and place, attention and concentration intact.
4) Early symptoms of vascular dementia include diminished reflexes, muscle weakness, and problems with gait.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders A child who has autistic disorder is likely to display symptoms of the illness by which age?
4 months
3 years
5 years
7 years
*1) Although it is difficult to give a definitive diagnosis of autism before 3 years of age, the child may show symptoms of autism, such as lack of social responsiveness, by 4 months of age.
2) See 1).
3) Autism is usually diagnosed by 3 years of age, but symptoms begin appearing during infancy.
4) See 3).
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
An elder patient in a nursing home suddenly becomes withdrawn, resistant, and disoriented. The RN's initial assessment should focus on which question?
Could the patient be depressed?
Has the patient had any recent visitors?
Is there a history of Alzheimer's disease in the patient's family? Is the patient physically ill?
1) A sudden change in behavior is not the result of depression.
2) This is not the initial assessment.
3) Withdrawn, resistant, and disoriented behaviors that occur suddenly are not indicative of Alzheimer's disease.
*4) This answer is correct, as the patient may be experiencing delirium.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
Which intervention is important for the RN to include in a discharge plan for a person newly diagnosed with early stage Alzheimer's disease?
Provide a diet low in protein and carbohydrates. Promote a stimulating environment.
Ignore experiences of delusions. Maintain a consistent daily routine.
1) No special dietary modifications are necessary in early stages of Alzheimer's disease. However, patients prefer familar food that appears appetizing.
2) See 4).
3) Early-stage Alzheimer's disease is not characterized by delusions.
*4) A goal is to promote patient independent functioning for as long as possible. A calm, predictable environment with consistent routine minimize disorientation and confusion. Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
Which intervention by the RN would be most appropriate to include when planning care for a resident in a nursing home who has a neurocognitive disorder?
Arrange furniture in way that prevents the patient from wandering. Assign the same staff to the patient as much as possible for consistency. Keep the head of bed (HOB) in an elevated position.
Provide as much auditory stimulation as possible to enhance the patient's mental alertness.
1) Placing furniture in odd places may create a fall risk. Patients with neurocognitive disorders are allowed to wander.
*2) Having consistent staff care for a patient allows staff to become familiar with a patient's behaviors, routines, and preferences. Having consistent staff also helps the patient feel less anxious.
3) Keep bed at lowest level to prevent falls.
4) Overstimulation can agitate patients with a neurocognitive disorder.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
An RN is caring for a child with a history of Attention deficit/Hyperactivity disorder (ADHD) who has been prescribed a selective serotonin reuptake inhibiter (SSRI) for the management of associated symptoms. What is the priority nursing assessment?
Changes in behavior Difficulty sleeping Delayed growth Gastrointestinal discomfort
*1) Antidepressants, including SSRIs, can cause changes in mood and behavior that can lead to suicide.
2) Although SSRIs may cause some patients to have difficulty sleeping, the priority is to monitor for change in mood that may indicate an increased suicide risk.
3) Delayed growth is a concern for children taking stimulants, not SSRIs.
4) Gastrointestinal discomfort can occur early in treatment with SRRIs. It generally resolves on its own.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
Haloperidol lactate (Haldol) 2.5 mg intramuscularly (IM) has been ordered for a patient with dementia who has become extremely agitated. What volume of medication should be administered, in milliliters (mL), if the Haldol comes in a vial with a concentration of 5 mg to 1 mL?
(Provide your answer to 1 decimal place in the input box below.) General: What you want is 1 mg/x; what you have is 5 mg/1 mL.
2.5 mg/x = 5 mg/1 mL 2.5 mg IM = 5 mg x (cancel mg on both sides of the equation) 1 mL - 5 mg x (divide both sides by 5 to get x alone to solve)
0.5 mL = x answer
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders Which result should the RN expect when using reminiscence therapy with patients who are older
adults?
Alteration of lifestyle practices Maintenance of orientation to reality Increased self-esteem
Improved adherence to treatment
1) Reawakening an older adult's interest in their environment so that they may consider an alteration of lifestyle practices is an outcome of remotivation therapy.
2) This is not an outcome of reminiscing therapy.
*3) Increased self-esteem is an expected outcome of reminiscing therapy.
4) See 2).
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
A community health nurse is making a home visit to assess the needs of an older adult with Alzheimer's disease. What nursing diagnosis statement should be the priority for this patient, based on Maslow's hierarchy of needs?
Anxiety related to cognitive losses and reduction in self-concept Self-Care Deficit related to confusion and disorientation
Impaired Social Interaction related to confusion and disorientation Risk for Injury related to impaired judgment
1) Maslow's hierarchy places biological needs above psychological needs. Of the two psychological diagnoses listed, this might be the first one to address after biological needs are met.
2) Self-care deficit can be seen as having a biological or physiological component, but is not essential to the patient's safety, so it would not be the priority.
3) Maslow's hierarchy places biological needs above psychological needs. Of the two psychological diagnoses listed, this might be the second one to address after biological needs are met.
*4) Risk for injury is an immediate need that falls in the biological category in Maslow's hierarchy.
Neurocognitive Impairment, Neurodevelopmental Disorders, Disruptive Behavior Disorders
An RN is providing teaching to the parents of a child with autism. Teaching has been effective when the parents express awareness that the child is placed at the greatest risk for injury by which of the following states?
Inappropriate affect Unresponsiveness to the environment
Excessive fearfulness Abnormal motor functioning
1) Inappropriate affect would not affect safety.
*2) Unresponsiveness would make the child unaware of their surroundings. This may put them at the greatest risk for injury.
3) This would not pose the greatest risk.
4) See 3).
Regulatory Disorders
The patient undergoing peritoneal dialysis has 1,800 mL of dialysate to dwell, consumes 10 ounces of fluid orally, and voids 60 mL of urine. When the dialysate is drained, 2,100 mL is obtained. The RN calculates the patient's total output for this period to be how many milliliters (mL)?
(Provide your answer rounded to the nearest whole number in the input box.) Total output is the difference between output minus intake.
The dialysate infused has drawn off 300 mL more fluid than the 1800 mL infused, thus showing 300 mL as output.
The patient voided 2 ounces (60 mL) of urine. (1 ounce = 30 mL) Therefore the total output for the patient is 360 mL.
Regulatory Disorders
A patient is brought to the emergency department (ED) with a headache after experiencing a head trauma from a motor vehicle accident. Currently, the patient reports increasing thirst and craves cold water. Which medical order by the health care provider should the RN question?
Infuse normal saline 0.9% at 50 mL/hr. Monitor the intake and output.
Obtain a urine sample for urinalysis. Take vital signs every 4 hours.
*1) Based on the current symptoms and clinical manifestations for head trauma from a motor vehicle accident, the patient has diabetes insipidus. The prescription to infuse normal saline 0.9% needs to be questioned, as this is an example of an isotonic solution. The patient needs to have a prescription order for a hypertonic saline solution, instead.
2) Monitoring of the patient's intake and output is important to avoid further problems related to dehydration, as it can occur for patients with diabetes insipidus, if not corrected.
3) Urinalysis is an appropriate order for diabetes insipidus to test for the specific urine gravity and presence of abnormal substances such as glucose or albumin.
4) Obtaining vital signs every 4 hours is appropriate to monitor for symptoms of dehydration. Regulatory Disorders
Which nursing action is best to help prepare the patient for a thyroid scan? Maintain nothing by mouth before the test.
Assess for any allergies. Obtain the vital signs.
Obtain a serum thyroid-stimulating hormone (TSH) test.
1) Maintaining nothing by mouth status is not required prior to a thyroid scan.
*2) It is important to ask about allergies to iodine (shellfish), medications, or agents that contain iodine, since they may alter the test results.
3) Obtaining the vital signs is routine prior to any test and is not the best action at this time.
4) Obtaining the blood work for TSH is not required prior to a thyroid scan. Regulatory Disorders
Which statement made by the patient indicates to the RN that the patient is ready to learn about newly prescribed thyroid replacement medication?
"My mother has been taking thyroid pills for years, so I'm very familiar with the medication." "I am so fatigued and depressed; I hope I can remember to take my pill."
"Leave the handout here. I will read it later."
"I am concerned about the best way to manage my medication and follow-up care."
1) The RN cannot assume that someone else's prior experience with a medication indicates correct knowledge about it.
2) The RN recognizes that psychological and emotional issues can interfere with patient education, with this statement.
3) The RN must obtain verbal feedback regarding information and instructions in order to evaluate patient learning.
*4) The RN recognizes that the patient is ready to learn because the patient expresses a need for the information, with this statement.
Regulatory Disorders
Which outcome does the RN identify as most appropriate for the patient who is being treated for renal calculi?
The patient cites the correct name and dosage of prescribed antibiotics. The patient maintains urinary output that is equivalent to fluid intake.
The patient achieves normal body temperature within 3 days. The patient acknowledges teaching about follow-up care.
1) Antibiotics may be prescribed to treat an infection before the stones are dissolved, but the ability to cite correct name and dosage is not a necessary or appropriate outcome for the patient.
*2) The patient should maintain a high fluid intake to avoid concentrated urine.
3) Fever is associated with the infections that may accompany renal calculi. This outcome is not appropriate for the problem stated.
4) The patient may acknowledge the teaching, but this does not ensure compliance. Regulatory Disorders
A 4-year-old pediatric patient with a new diagnosis of diabetes insipidus has a urine specific gravity of 1.025. The RN considers which of the following interventions to be the priority?
Administer an isotonic fluid ordered by the health care provider. Encourage the patient to drink 3 liters of liquid each day.
Have a bedside commode next to the patient's bed. Recommend the parents carry bottled water for travel.
1) This would not be appropriate, as the urine specific gravity is WNL, which is not indicative of dehydration in this child.
2) This child does not need to drink extra fluids. This may cause an increase in urine excretion and increase the urine specific gravity out of normal range.
3) This child should not have increased urination and will not need a bedside commode, also there is no mention in the question of change in mental status.
*4) Carrying bottled water will make it available during travel and can help prevent dehydration. Regulatory Disorders
An RN identifies which information in a patient's health history as being consistent with a diagnosis of hyperthyroidism?
(Select all that apply.)
Weight gain Bradycardia Diarrhea Increased appetite Mental confusion
1) A patient with hyperthyroidism is more likely to lose weight.
2) A patient with hyperthyroidism is more likely to have an increased heart rate.
*3) Changes in bowel function are causes in hyperthyroidism.
*4) Increased appetite is common in hyperthyroidism.
*5) Cognitive changes are characteristics of hyperthyroidism. Regulatory Disorders
Which safety measures should the RN implement for a patient who has Cushing's disease? Keep suctioning equipment at the patient's bedside.
Maintain the head of bed (HOB) at 90 degrees at all times. Pad the side rails of the patient's bed.
Use a lift sheet to change the patient's position.
1) There is no indication for this intervention with Cushing's disease.
2) See 1).
3) See 1).
*4) Cushing's disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fractures. Using a lift sheet to change the patient's position will decrease the risk of fractures.
Regulatory Disorders
An RN is preparing to discharge a patient hospitalized for chronic glomerulonephritis. Which of the following factors could inhibit the patient's recovery after being discharged to home care?
Inability to drive to future appointments Ability to read at a sixth grade level or higher Consistently monitoring daily weight Maintaining adequate dietary needs
*1) This is the correct reason that could inhibit recovery.
2) This would promote patient recovery.
3) This will help with patient recovery.
4) This will help with encouraging the patient recovery. Regulatory Disorders
An RN is teaching a patient about the acute complication of peritoneal dialysis. The patient demonstrates an understanding when agreeing to report which of the following symptoms?
Change in mentation Severe rebound tenderness
Diffuse abdominal pain Cloudy drainage fluid
1) Change in mentation is not an initial or first sign, but rather a late sign of peritonitis.
2) Severe rebound tenderness is a later sign of peritonitis.
3) Diffuse abdominal pain is a later sign of peritonitis.
*4) As the patient is draining the dialysate from the abdominal cavity, it should be clear drainage. If the drainage is cloudy, it should be reported to a health care provider for further consideration, as it is the first indication of peritonitis.
Regulatory Disorders
A patient is being discharged with continuous ambulatory peritoneal dialysis. The RN recognizes that further family teaching is needed when the caregiver makes which statement?
"It is very important to care for the catheter site carefully."
"There aren't too many diet restrictions with CAPD, so the diet is easier to follow." "We will notify the health care provider if the dialysate return is cloudy."
"If the dialysate does not drain quickly, we should push the catheter in deeper."
1) This will help prevent infection, which could lead to peritonitis.
2) Peritoneal dialysis patients have a more liberal diet and fluid intake than patients undergoing hemodialysis.
3) Cloudy dialysate fluid is a symptom of peritonitis and should be reported immediately.
*4) The catheter is held securely by Dacron cuffs and should never be pushed further into the abdomen. To assist fluid to drain, the nurse should turn the patient from side-to-side, or raise the head of the bed.
Regulatory Disorders
A patient expresses concern about developing a moon face while on corticosteroid therapy. Which would be the best response by the RN?
"The added weight will enhance the effectiveness of the medication."
"If this is still a concern next week, I will have the doctor talk with you."
"Most changes in appearance are temporary and will disappear when therapy is no longer necessary."
"No one will notice the change in your appearance except you and your family."
1) The added weight is a result of the medication, not something that will enhance its effectiveness. Attention to diet, including lower carbohydrate and sodium intake, can reduce the weight gain and edema over time.
2) The moon face is a condition most appropriately discussed by the nurse and patient as soon as the concern is raised. The doctor's intervention should not be needed.
*3) This response correctly states the nature and duration of the effect. The statement should be followed by further discussion of the patient's feelings about the changes in body image.
4) This response treats the patient's concern as not very serious, implying that the family's feelings about the changes are not important.
Regulatory Disorders
During the change of shift report, the outgoing RN tells the incoming RN that the patient's arteriovenous fistula (AVF) on the left arm is not working properly. Which nursing action should the RN perform first?
Verify the findings from the electronic health record. Assess the arteriovenous fistula for patency.
Notify the primary care provider immediately. Put up a sign stating, "No BP on the right arm."
1) Verifying the findings from the electronic health record about the malfunctioning AVF is not a priority. The RN needs to assess the site first to confirm what was communicated during the change of shift report.
*2) Assess the site for patency by palpating for a thrill and listening with a stethoscope for an audible bruit to confirm if there is any problem.
3) Notifying the primary care provider is not the first step. The RN needs to assess the site first to confirm if there is any problem.
4) The signage is incorrect. It should state "No BP on the left arm," as the AVF is located in that extremity. Written communication must be correct to avoid errors in patient care.
Regulatory Disorders
A patient is exhibiting exophthalmos, weight loss, tachycardia, low serum TSH level, and high serum T4 level. Which priority nursing diagnosis statement will the RN identify?
Activity Intolerance related to decreased metabolic rate
Altered Bowel Elimination (Constipation) related to decreased intestinal motility Imbalanced Nutrition: Less than Body Requirements related to weight loss despite excessive appetite
Self-Care Deficits related to fatigue and depression
1) Symptoms and diagnostic data are suggestive of hyperthyroidism, not hypothyroidism.
2) See 1).
*3) Symptoms and diagnostic data are suggestive of hyperthyroidism and hypermetabolic state manifested by weight loss despite extreme appetite.
4) See 1).
Regulatory Disorders
In caring for a patient with edema associated with nephrotic syndrome, the RN must carefully monitor the use of diuretics for which reason?
Diuretics tend to impair sodium and potassium regulation. Diuretics prevent the effectiveness of necessary ACE inhibitors. Reduced plasma volume may precipitate acute renal failure.
Excessive amounts of albumin will be excreted.
1) Some diuretics affect sodium and/or potassium regulation, while others do not. This is not the primary reason for monitoring the use of diuretics for a patient with nephrotic syndrome.
2) Some diuretics, notably spironolactone (Aldactone) enhance the effectiveness of ACE inhibitors.
*3) The volume of extracellular fluid removed by use of diuretics can bring on hypovolemia (shock), leading to acute renal failure.
4) The excretion of excess albumin is a defining feature of nephrotic syndrome, not an effect of diuretics given to treat the condition.
Metabolic Disorders
A patient with a history of biliary cirrhosis had a liver transplant 6 months earlier. The patient also recently experienced the death of a child. The RN suspects the patient has stopped taking their immunosuppressive therapy. Which response by the RN is most appropriate?
"If you do not take your immunosuppressive medications, your new liver may fail." "I am going have to tell your doctor that you are no longer taking your medications." "Do you understand how important it is to continue to take your medications?"
"Are you still taking your immunosuppressive medications, as ordered?"
1) This response is not therapeutic. The RN only suspects the patient is not taking the medication, so it would be most appropriate for the RN to ask the patient if he or she is taking the medication first.
2) See 1).
3) This response sounds judgmental. The RN should ask if the therapy was stopped without sounding judgmental.
*4) This response is most appropriate because it allows the patient to provide information to the RN by answering the question.
Metabolic Disorders [Show Less]