Essentials Of Psychiatric Mental Health Nursing

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Essentials Of Psychiatric Mental Health Nursing - Quiz

The need for psychiatric mental health nursing has its roots near the end of the 19th century when it was believed that patients in mental hospitals should receive nursing care. Psychiatric mental health nursing has since come a long way, with psychiatric-mental health content incorporated into all diploma and baccalaureate nursing programs. As new needs for services developed in the health care arena, the role and function of the psychiatric-mental health nurse expanded, leading to advanced practice registered nurses in psychiatric-mental health nursing (APRN-PMH). Psychiatric-mental health nurses are a rich resource as providers of psychiatric-mental health services and patient care Read morepartners for the consumers of those services.


Questions and Answers
  • 1. 

    A paA patient is referred to the mental health center by the family health care provider. Over the past year, the patient has cooked gourmet meals for family members, but eats only tiny portions of the food. The patient wears layers of loose clothing, saying, “It’s just my style.” The patient’s weight has dropped from 130 to 95 pounds. The patient has amenorrhea. The history and symptoms are most consistent with which medical diagnosis?

    • A.

      Anorexia nervosa

    • B.

      Bulimia nervosa

    • C.

      Binge eating

    • D.

      Eating disorder not otherwise specified

    Correct Answer
    A. Anorexia nervosa
    Explanation
    ANS: A
    Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.

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  • 2. 

    DisDisturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor?

    • A.

      Weight, muscle, and fat congruence with height, frame, age, and sex

    • B.

      Calorie intake within required parameters of treatment plan

    • C.

      Weight at established normal range for the patient

    • D.

      Patient satisfaction with body appearance

    Correct Answer
    D. Patient satisfaction with body appearance
    Explanation
    ANS: D
    Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

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  • 3. 

    A patient referred to the eating disorders clinic has lost 35 pounds during one summer. To assess the patient’s eating patterns, the nurse should ask:

    • A.

      “Do you often feel fat?”

    • B.

      “Who plans the family meals?”

    • C.

      “What do you eat in a typical day?”

    • D.

      “What do you think about your present weight?”

    Correct Answer
    C. “What do you eat in a typical day?”
    Explanation
    ANS: C
    Although all the questions might be appropriate to ask, only “What do you eat in a typical day?” focuses on the patient’s eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient’s thoughts on present weight explores the patient’s feelings about weight.

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  • 4. 

    A patient is diagnosed with anorexia nervosa. The history reveals the patient virtually stopped eating 5 months ago and lost 25% of body weight. A nurse tells the patient, “Describe what you think about your present weight and how you think you look.” Which response would be most consistent with the diagnosis?  

    • A.

      “I’m fat and ugly.”

    • B.

      “What I think about myself is my business.”

    • C.

      “I’m grossly underweight, but thin is interesting.”

    • D.

      “I’m a few pounds overweight, but I can live with it.”

    Correct Answer
    A. “I’m fat and ugly.”
    Explanation
    ANS: A
    Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness, and will persist in trying to lose more weight.

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  • 5. 

    A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient with anorexia nervosa. Which statement by the nurse supports this type of therapy?  

    • A.

      “What are your feelings about not eating the food that you prepare?”

    • B.

      “You seem to feel much better about yourself when you eat something.”

    • C.

      “It must be difficult to talk about private matters to someone you just met.”

    • D.

      “Being thin doesn’t seem to solve your problems. You’re thin now but still unhappy.”

    Correct Answer
    D. “Being thin doesn’t seem to solve your problems. You’re thin now but still unhappy.”
    Explanation
    ANS: D
    The fourth statement is the only strategy that attempts to question the patient’s distorted thinking.

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  • 6. 

    A student transferred from a hometown community college to a university 100 miles from home. She was slow to make new friends at the university. The history shows a close relationship with her mother and sister and that she broke up with her boyfriend of 2 years. She began to eat large quantities when she felt sad, and then induce vomiting. These cycles continued until they interfered with her schoolwork. She sought help from the university health clinic. During the initial interview, what other priority issue should a nurse address?

    • A.

      Sleep patterns

    • B.

      School activities

    • C.

      Losses

    • D.

      Menstrual flow

    Correct Answer
    C. Losses
    Explanation
    ANS: C
    The patient has a significant history of losses: her mother and sister are no longer available as supports, she has terminated the relationship with her boyfriend, and she has moved from her hometown. Feelings of loss and depression are often associated with bulimia. The other options are of lesser relevance.

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  • 7. 

    One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from:

    • A.

      150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg

    • B.

      120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg

    • C.

      110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg

    • D.

      90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

    Correct Answer
    A. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg
    Explanation
    ANS: A
    Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

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  • 8. 

    A patient with an eating disorder has been under significant stress and works long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. The patient is 5 feet tall and weighs 175 pounds. A desired outcome for the patient is to recognize the anxiety that precedes binge eating and reduce it with a constructive strategy. Which intervention addresses the outcome?  

    • A.

      Teach stress reduction techniques such as relaxation and imagery.

    • B.

      Explore the patient’s need to single-handedly make up for a staff shortage.

    • C.

      Explore ways in which the patient may feel in control of the environment.

    • D.

      Encourage the patient to attend a support group such as Overeaters Anonymous.

    Correct Answer
    A. Teach stress reduction techniques such as relaxation and imagery.
    Explanation
    ANS: A
    Teaching alternative stress reduction techniques that may be substituted for overeating most directly addresses the goal of replacing binge eating with a constructive anxiety-releasing activity. The other options offer interventions that better relate to other outcomes.

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  • 9. 

    A patient being admitted to the eating disorders unit has a yellow cast to the skin, has hair that is limp and dry, and has fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet and sullen during the physical assessment saying only, “I don’t intend to eat until I lose enough weight to look thin.” What is the best initial nursing diagnosis?  

    • A.

      Disturbed body image related to weight loss

    • B.

      Anxiety related to fear of weight gain

    • C.

      Ineffective coping related to lack of conflict resolution skills

    • D.

      Imbalanced nutrition: less than body requirements related to self-starvation

    Correct Answer
    D. Imbalanced nutrition: less than body requirements related to self-starvation
    Explanation
    ANS: D
    The physical assessment by the nurse revealed cachexia; thus the diagnosis of Imbalanced nutrition. No defining characteristics support the other diagnoses.

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  • 10. 

    Nursing physical assessment of a patient with bulimia often reveals:

    • A.

      Prominent parotid glands.

    • B.

      Peripheral edema.

    • C.

      Thin, brittle hair.

    • D.

      Amenorrhea.

    Correct Answer
    A. Prominent parotid glands.
    Explanation
    ANS: A
    Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually seen in bulimia.

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  • 11. 

    When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed upon weekly weight, the nurse should state:

    • A.

      “It bothers me to see you exercising. You’ll lose more weight.”

    • B.

      “You and I will have to sit down and discuss this problem.”

    • C.

      “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”

    • D.

      “Let’s discuss the relationship between exercise and weight loss and how that affects your body.”

    Correct Answer
    C. “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”
    Explanation
    ANS: C
    Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

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  • 12. 

    A patient referred to the eating disorders clinic has lost 35 pounds during the summer and developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? (More than one answer is correct.)

    • A.

      Peripheral edema

    • B.

      Parotid swelling

    • C.

      Constipation

    • D.

      Hypotension

    • E.

      Dental caries

    • F.

      Lanugo

    Correct Answer(s)
    A. Peripheral edema
    C. Constipation
    D. Hypotension
    F. Lanugo
    Explanation
    ANS: A, C, D, F
    Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

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  • 13. 

    When a patient with anorexia is admitted for treatment, what should the milieu provide? (More than one answer is correct.)

    • A.

      Flexible mealtimes

    • B.

      Adherence to a selected menu

    • C.

      Observation during and after meals

    • D.

      Unscheduled weight checks

    • E.

      Monitoring during bathroom trips

    • F.

      Privileges correlated with affective display

    Correct Answer(s)
    B. Adherence to a selected menu
    C. Observation during and after meals
    E. Monitoring during bathroom trips
    Explanation
    ANS: B, C, E
    Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient’s eating and prevention of exercise, purging, and so forth. Menus are strictly adhered to. Observation is maintained during and after meals to prevent throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are precisely observed, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

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  • 14. 

    An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?  

    • A.

      Between 0800 and 1000 today (6 to 8 hours after drinking stopped)

    • B.

      Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)

    • C.

      About 0200 on hospital day 3 (72 hours after drinking stopped)

    • D.

      About 0200 on hospital day 4 (96 hours after drinking stopped)

    Correct Answer
    A. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
    Explanation
    ANS: A
    Alcohol withdrawal usually begins 6 to 8 hours after cessation or marked reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

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  • 15. 

    A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated. The medical record shows the following blood pressure and pulse readings: Admission, 0200—122/80 mm Hg and 72 beats/min; 0400—126/78 mm Hg and 76 beats/min; 0600—124/80 mm Hg and 72 beats/min; 0800—132/88 mm Hg and 80 beats/min; 1000—148/88 mm Hg and 96 beats/min. What is the nurse’s priority action?

    • A.

      Encourage the patient to drink plenty of liquids.

    • B.

      Obtain a clean-catch urine sample.

    • C.

      Place the patient in a vest-type restraint.

    • D.

      Consult the health care provider.

    Correct Answer
    D. Consult the health care provider.
    Explanation
    ANS: D
    Elevated pulse and blood pressure may indicate that the patient is going into withdrawal delirium and that additional sedation is warranted. None of the other options takes into account the possible need for sedation. No indication is present that the patient may have a urinary tract infection or is currently in need of restraint. Hydration will not resolve the problem.

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  • 16. 

    A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is shaky, irritable, anxious, and diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here,” and begins to thrash about. The most accurate assessment of the situation would be that the patient:  

    • A.

      Is attempting to obtain attention by manipulating staff.

    • B.

      May have sustained a head injury before admission.

    • C.

      Is having a recurrence of an acute psychosis.

    • D.

      Has symptoms of alcohol withdrawal delirium.

    Correct Answer
    D. Has symptoms of alcohol withdrawal delirium.
    Explanation
    ANS: D
    Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

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  • 17. 

    A patient admitted yesterday for injuries sustained in a fall while intoxicated believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?

    • A.

      A benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium)

    • B.

      A phenothiazine, such as chlorpromazine (Thorazine) or thioridazine (Mellaril)

    • C.

      A monoamine oxidase inhibitor, such as phenelzine (Nardil)

    • D.

      A narcotic analgesic, such as codeine

    Correct Answer
    A. A benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium)
    Explanation
    ANS: A
    Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

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  • 18. 

    A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention should be instituted?  

    • A.

      Check the patient every 15 minutes.

    • B.

      Provide one-on-one supervision.

    • C.

      Keep the room dimly lit.

    • D.

      Rigorously encourage fluid intake.

    Correct Answer
    B. Provide one-on-one supervision.
    Explanation
    ANS: B
    One-on-one supervision is necessary to promote physical safety until sedation reduces the patient’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Excessive fluid intake can cause overhydration because fluid retention normally occurs when blood alcohol levels fall.

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  • 19. 

    A patient experienced alcohol withdrawal delirium, but now has a clear sensorium. The patient says, “Drinking helps me cope with being a single parent.” Which response by the nurse would help the patient conceptualize the drinking more objectively?

    • A.

      “Sooner or later, alcohol will kill you. Then what will happen to your children?”

    • B.

      “I hear a lot of defensiveness in your voice. Do you really believe this?”

    • C.

      “If you were coping so well, why were you hospitalized again?”

    • D.

      “Tell me what happened the last time you drank.”

    Correct Answer
    D. “Tell me what happened the last time you drank.”
    Explanation
    ANS: D
    This response will help the patient see alcohol as a cause of the problems, not a solution. This approach can also help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.

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  • 20. 

    During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, “After discharge, I’m sure everything will be just fine.” Which remark by the nurse will be most helpful to the spouse?  

    • A.

      “It is good that you’re supportive of your spouse’s sobriety and want to help maintain it.”

    • B.

      “Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.”

    • C.

      “It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.”

    • D.

      “Remember that alcoholism is a disease of self-destruction. You will need to observe your spouse’s behavior carefully.”

    Correct Answer
    B. “Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.”
    Explanation
    ANS: B
    During recovery, patients identify and use alternative coping mechanisms to reduce reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance. The nurse should provide anticipatory guidance and accurate information.

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  • 21. 

    In the emergency department, a patient’s vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. Naloxone (Narcan) is administered. The nursing diagnosis is “ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose.” Select the desired outcome.

    • A.

      Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above12 breaths/min.

    • B.

      The patient will be able to describe a plan for home care and achieving a drug-free state before release from the emergency department.

    • C.

      The patient will demonstrate effective coping skills within 1 week of hospitalization.

    • D.

      The patient will identify two community resources for treatment of substance abuse by discharge.

    Correct Answer
    A. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above12 breaths/min.
    Explanation
    ANS: A
    This short-term outcome is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the central nervous system (CNS) depression is alleviated.

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  • 22. 

    A nurse worked at a community hospital for several months, resigned, then took a position at another hospital. In the new position, the nurse volunteered or switched with others to be the medication nurse. After a year, several serious medication errors occurred in rapid succession. During the investigation, it was learned that the nurse was allowed to resign from the community hospital after diverting patient narcotics for self-use. The nurse manager could retrospectively identify which early indicator of the nurse’s drug use?  

    • A.

      Accepting responsibility for medication errors.

    • B.

      High sociability with peers.

    • C.

      Seeking to be assigned as medication nurse.

    • D.

      Presenting a neat physical appearance.

    Correct Answer
    C. Seeking to be assigned as medication nurse.
    Explanation
    ANS: C
    The nurse intent on diverting drugs for personal use or who uses drugs while on duty usually attempts to isolate from peers and may manipulate others to gain access to medications. Appearance often deteriorates and errors are blamed on others.

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  • 23. 

    A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred from the emergency department to the inpatient psychiatric unit. Which attitudes or behaviors on the part of nursing staff may be enabling behaviors?

    • A.

      Conveying understanding that pressures experienced in nursing underlie substance use.

    • B.

      Pointing out that work problems are the result, but not the cause, of substance abuse.

    • C.

      Empathizing when the nurse discusses fears of disciplinary action by the state board of nursing.

    • D.

      Providing health teaching about stress management.

    Correct Answer
    A. Conveying understanding that pressures experienced in nursing underlie substance use.
    Explanation
    ANS: A
    Enabling denies the seriousness of the patient’s problem or supports the patient as he or she shifts responsibility from self to circumstances. The other options are therapeutic and appropriate.

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  • 24. 

    A nurse manager tells the staff nurse, “We anticipate this patient will have symptoms of withdrawal from sedative-hypnotics, so close observation is needed.” For which symptoms should the staff nurse assess the patient?  

    • A.

      Dilated pupils, tachycardia, elevated blood pressure, elation

    • B.

      Mood lability, incoordination, fever, drowsiness

    • C.

      Nausea, vomiting, diaphoresis, anxiety, tremors

    • D.

      Excessive eating, constipation, headache

    Correct Answer
    C. Nausea, vomiting, diaphoresis, anxiety, tremors
    Explanation
    ANS: C
    The symptoms of withdrawal from sedative-hypnotic or anxiolytic drugs are similar to those of alcohol withdrawal. Generalized seizures are possible. All are CNS depressants.

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  • 25. 

    A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?

    • A.

      Substance abuse

    • B.

      Substance intoxication

    • C.

      Substance dependence

    • D.

      Recreational use of a social drug

    Correct Answer
    C. Substance dependence
    Explanation
    ANS: C
    Nicotine meets the criteria for “substance,” the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or recreational use of a social drug.

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  • 26. 

    In what significant way should the therapeutic environment differ for a patient who ingested LSD from that for a patient who ingested PCP?

    • A.

      For LSD ingestion, have one person stay with the patient and provide verbal support. For PCP ingestion, maintain a regimen of limited contact with one staff member accompanied by two or more staff.

    • B.

      For PCP ingestion, place patient on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.

    • C.

      For LSD ingestion, provide continual moderate sensory stimulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.

    • D.

      For LSD ingestion, place the patient in restraints. For PCP ingestion, place the patient on seizure precautions.

    Correct Answer
    A. For LSD ingestion, have one person stay with the patient and provide verbal support. For PCP ingestion, maintain a regimen of limited contact with one staff member accompanied by two or more staff.
    Explanation
    ANS: A
    Patients who have ingested LSD respond well to being “talked down” by a supportive person. Patients who have ingested PCP are very stimulation sensitive and display frequent, unpredictable, violent behavior. While one person should perform care and talk gently to the patient, no one should be alone in the room with the patient. Take adequate staff to manage violent behavior if it occurs.

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  • 27. 

    A patient in an alcohol rehabilitation program says, “I have been a loser all my life. I’m so ashamed of what I put my family through. Now I’m not even sure I can succeed at staying sober.” Which nursing diagnosis applies?

    • A.

      Chronic low self-esteem

    • B.

      Situational low self-esteem

    • C.

      Ineffective health maintenance

    • D.

      Disturbed personal identity

    Correct Answer
    A. Chronic low self-esteem
    Explanation
    ANS: A
    Low self-esteem is present when a patient sees the self as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

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  • 28. 

    A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which needs should be included in discharge teaching for the patient? (More than one answer is correct.)

    • A.

      Read labels of all liquid medications.

    • B.

      Avoid aged cheeses.

    • C.

      Avoid alcohol-based skin products.

    • D.

      Wear sunscreen and avoid bright sunlight.

    • E.

      Maintain an adequate dietary intake of sodium.

    • F.

      Refrain from eating foods prepared with alcohol.

    • G.

      Avoid breathing fumes of paints, stains, and stripping compounds.

    Correct Answer(s)
    A. Read labels of all liquid medications.
    C. Avoid alcohol-based skin products.
    F. Refrain from eating foods prepared with alcohol.
    G. Avoid breathing fumes of paints, stains, and stripping compounds.
    Explanation
    ANS: A, C, F, G
    The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

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  • 29. 

    A nurse can assist a patient and family in which aspects of substance abuse relapse prevention? (More than one answer is correct.)  

    • A.

      Advising the patient to accept residential treatment if relapse occurs

    • B.

      Assisting the patient to identify life skills needed for effective coping

    • C.

      Rehearsing techniques to handle anticipated stressful situations

    • D.

      Isolating self from significant others and social situations until sobriety is established

    • E.

      Education about physical changes to expect as the body adapts to functioning without substances

    Correct Answer(s)
    B. Assisting the patient to identify life skills needed for effective coping
    C. Rehearsing techniques to handle anticipated stressful situations
    E. Education about physical changes to expect as the body adapts to functioning without substances
    Explanation
    ANS: B, C, E
    Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations. The nurse can participate in role playing and can help the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes that can be expected and ways in which to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

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  • 30. 

    After a methamphetamine overdose, on which tasks will priority nursing and medical measures focus? (More than one answer is correct.)

    • A.

      Administration of naloxone (Narcan)

    • B.

      Vitamin B12 and folate supplements

    • C.

      Restoring nutritional integrity

    • D.

      Reduction of fever

    • E.

      Prevention of seizures

    Correct Answer(s)
    D. Reduction of fever
    E. Prevention of seizures
    Explanation
    ANS: D, E
    Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

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  • 31. 

    A community health nurse makes a home visit to a family with four children. The father behaves angrily, finds fault with a child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” The nurse seeks to gather more assessment data. Which comments by the nurse will facilitate communication? (More than one answer is correct.)  

    • A.

      “Tell me how you punish your children.”

    • B.

      “How do you stop your baby’s crying?”

    • C.

      “Caring for four small children must be difficult.”

    • D.

      “Do you or your husband ever beat the children?”

    • E.

      “Calling children stupid injures their self-esteem.”

    Correct Answer(s)
    A. “Tell me how you punish your children.”
    B. “How do you stop your baby’s crying?”
    C. “Caring for four small children must be difficult.”
    Explanation
    ANS: A, B, C
    An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

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  • 32. 

    A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? (More than one answer is correct.)  

    • A.

      Keeping a cell phone fully charged

    • B.

      Hiding money with which to buy new clothes

    • C.

      Having the phone number for the nearest shelter

    • D.

      Taking enough toys to amuse the children for 2 days

    • E.

      Securing a supply of current medications for self and children

    • F.

      Determining a code word to signal children it is time to leave

    • G.

      Assembling birth certificates, Social Security cards, and licenses

    Correct Answer(s)
    A. Keeping a cell phone fully charged
    C. Having the phone number for the nearest shelter
    E. Securing a supply of current medications for self and children
    F. Determining a code word to signal children it is time to leave
    G. Assembling birth certificates, Social Security cards, and licenses
    Explanation
    ANS: A, C, E, F, G
    The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

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  • 33. 

    A community health nurse visits the home of a child, age 11, to investigate frequent school absences. The nurse finds the child caring for three siblings, all younger than age 4. Both parents are at work. The child says, “I want to go to school regularly, but when my mother has to work, I watch the kids. We can’t afford a babysitter. It doesn’t matter anyway. I’m too dumb to learn much. I don’t have friends at school, probably because I don’t deserve any.” What preliminary assessment can be made?

    • A.

      Insufficient data are present to make an assessment.

    • B.

      The child and siblings are experiencing neglect.

    • C.

      The children are at high risk for sexual abuse.

    • D.

      The children are experiencing physical abuse

    Correct Answer
    B. The child and siblings are experiencing neglect.
    Explanation
    ANS: B
    The child is experiencing neglect when the parents take away the opportunity to attend school. It is possible that the other children may be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate high risk for sexual abuse, and no concrete evidence of physical abuse is present.

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  • 34. 

    What is a nurse’s legal responsibility if child abuse or neglect is suspected?

    • A.

      Discuss the findings with the child’s teacher, principal, and school psychologist.

    • B.

      Report the suspected abuse or neglect according to state regulations.

    • C.

      Document the observations and speculations in the medical record.

    • D.

      Continue the assessment.

    Correct Answer
    B. Report the suspected abuse or neglect according to state regulations.
    Explanation
    ANS: B
    Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be absolutely sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

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  • 35. 

    An 11-year-old stays home from school to care for siblings while the parents work. When asked about the parents, the child reluctantly says, “My parents don’t like me. They call me stupid and say I never do anything right.” The level of prevention for work with this family will be:

    • A.

      Primary.

    • B.

      Secondary.

    • C.

      Tertiary.

    • D.

      Prevention is not possible.

    Correct Answer
    B. Secondary.
    Explanation
    ANS: B
    Secondary prevention involves intervention in abusive situations to minimize their disabling or long-term effects. Community resources are mobilized to help find alternative ways to deal with stress. Primary prevention refers to measures to prevent or reduce the occurrence of abusive situations. Tertiary prevention refers to interventions aimed at reducing the severity of mental illness or handicaps resulting from long-term, abusive trauma.

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  • 36. 

    An 11-year-old stays home from school to care for siblings while the parents work. The child says, “My parents don’t like me. They call me stupid and say I never do anything right.” The child also says, “It doesn’t matter anyway. I’m too dumb to learn much. I don’t have friends at school and probably don’t deserve any.” Which nursing diagnosis applies to this child?

    • A.

      Chronic low self-esteem related to negative feedback about self from parents

    • B.

      Deficient knowledge related to interpersonal skills with parents

    • C.

      Noncompliance: school attendance related to parental rules

    • D.

      Disturbed personal identity related to negative self-evaluation

    Correct Answer
    A. Chronic low self-esteem related to negative feedback about self from parents
    Explanation
    ANS: A
    The child has indicated a belief in being too dumb to learn and in not deserving to have friends. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Noncompliance refers to an individual’s informed decision not to adhere to a therapeutic recommendation. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self.

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  • 37. 

    A person tells the nurse, “My spouse abuses me most often when intoxicated. The drinking has increased lately, but I always receive an apology afterward and a box of chocolates. I’ve considered leaving home but haven’t been able to bring myself to actually leave.” Which phase in the cycle of violence prevents the patient from leaving?  

    • A.

      Tension-building

    • B.

      Acute battering

    • C.

      Honeymoon

    • D.

      Recovery

    Correct Answer
    C. Honeymoon
    Explanation
    ANS: C
    The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

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  • 38. 

    A victim of domestic abuse is treated for a detached retina. The patient tells the nurse, “My partner only abuses me when intoxicated. I’ve considered going to a safe house, but I was brought up to believe you stay together, no matter what happens. I always receive an apology and I can tell my spouse feels bad after hitting me.” Which nursing diagnosis has priority?

    • A.

      Social isolation related to lack of community support system

    • B.

      Risk for injury related to spouse’s physical abuse when intoxicated

    • C.

      Deficient knowledge related to resources for escape from the abusive relationship

    • D.

      Disabled family coping related to uneven distribution of power within the marital relationship

    Correct Answer
    B. Risk for injury related to spouse’s physical abuse when intoxicated
    Explanation
    ANS: B
    Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data have not been obtained showing social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge cannot be substantiated because the patient is aware of a safe house.

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  • 39. 

    A victim of physical abuse by the domestic partner is treated for a broken wrist. The patient has considered going to a safe house, but cites being brought up to believe “you stay together, no matter what happens.” The patient says the partner is always apologetic and remorseful after an incident. Which outcome should be met before the patient leaves the emergency department? The patient will:

    • A.

      Name two community resources that can be contacted.

    • B.

      Demonstrate insight into the abusive relationship.

    • C.

      Limit contact with the perpetrator by a restraining order.

    • D.

      Facilitate counseling for the perpetrator.

    Correct Answer
    A. Name two community resources that can be contacted.
    Explanation
    ANS: A
    The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the perpetrator’s counseling may require weeks or months.

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  • 40. 

    An older adult with Alzheimer’s disease lives with family and goes to day care on weekdays. The nurse at the center observed an unkempt appearance and multiple bruises. The nurse discussed these observations with the daughter, who became defensive and said, “My mother is so difficult to manage. She wanders all night. Last night she fell down the stairs. Sometimes I just can’t bear to care for her.” Which nursing diagnosis has priority?  

    • A.

      Risk for injury related to poor judgment, cognitive impairment, and lack of caregiver supervision

    • B.

      Noncompliance related to confusion and disorientation as evidenced by lack of cooperation

    • C.

      Insomnia related to cognitive impairment as evidenced by wandering at night

    • D.

      Impaired verbal communication related to brain impairment as evidenced by the confusion

    Correct Answer
    A. Risk for injury related to poor judgment, cognitive impairment, and lack of caregiver supervision
    Explanation
    ANS: A
    The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. No assessment data support the diagnoses of Impaired verbal communication, or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the Risk for injury is a higher priority.

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  • 41. 

    Which family scenario presents the greatest risk for family violence?

    • A.

      An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

    • B.

      A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school

    • C.

      A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care

    • D.

      A single homosexual male parent, an adolescent son who has just begun

    Correct Answer
    A. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
    Explanation
    ANS: A
    The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

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  • 42. 

    A child stays home from school to care for siblings while the parents work because the family cannot afford a babysitter. The home is cluttered and dirty. The child reveals, “My father doesn’t like me very much. He calls me stupid all the time.” The wife mentions that the father is easily frustrated and has trouble disciplining the children. In planning interventions to stabilize the home situation, the community health nurse should consider which resources? (More than one answer is correct.)

    • A.

      Anger management counseling for the father

    • B.

      Placing the children in a children’s shelter

    • C.

      Continuing home visits to give support

    • D.

      Group sessions to teach childrearing practices

    • E.

      A safety plan for the wife and children

    Correct Answer(s)
    A. Anger management counseling for the father
    C. Continuing home visits to give support
    D. Group sessions to teach childrearing practices
    Explanation
    ANS: A, C, D
    Anger management counseling for the father would be appropriate. Support for this family will be an important component of treatment. By the wife’s admission the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.

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  • 43. 

    A nurse in the emergency department explains to a victim of domestic violence that the psychosocial history, statements about battering, body map, and photos will be placed in the medical record. The victim says, “Oh, no, what if my spouse finds out?” What information regarding the medical record can the nurse give the patient to help with acceptance of the documentation? (More than one answer is correct.)

    • A.

      It is not available to the perpetrator or perpetrator’s legal counsel.

    • B.

      It will be valuable to the patient if legal action is pursued later.

    • C.

      It makes pertinent information available to other care providers.

    • D.

      It will provide evidence to law enforcement if another incident occurs.

    • E.

      It can be a resource to providers of treatment to the perpetrator or the victim.

    Correct Answer(s)
    A. It is not available to the perpetrator or perpetrator’s legal counsel.
    B. It will be valuable to the patient if legal action is pursued later.
    C. It makes pertinent information available to other care providers.
    Explanation
    ANS: A, B, C
    The medical record is a powerful tool if legal action is initiated. Even if legal action is not taken at the time, the record is begun and the next provider will not have to stumble across the problem and will be in a better position to offer support.

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  • 44. 

    A community health nurse makes a home visit to a family with four children. The father behaves angrily, finds fault with a child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” The nurse seeks to gather more assessment data. Which comments by the nurse will facilitate communication? (More than one answer is correct.)  

    • A.

      “Tell me how you punish your children.”

    • B.

      “How do you stop your baby’s crying?”

    • C.

      “Caring for four small children must be difficult.”

    • D.

      “Do you or your husband ever beat the children?”

    • E.

      “Calling children stupid injures their self-esteem.”

    Correct Answer(s)
    A. “Tell me how you punish your children.”
    B. “How do you stop your baby’s crying?”
    C. “Caring for four small children must be difficult.”
    Explanation
    ANS: A, B, C
    An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

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  • 45. 

    A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, “I can’t talk about it. Nothing happened. I have to forget!” What is the patient’s present coping strategy?

    • A.

      Somatic reaction

    • B.

      Denial

    • C.

      Repression

    • D.

      Projection

    Correct Answer
    B. Denial
    Explanation
    ANS: B
    The patient’s statements reflect use of the ego defense mechanism denial. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of the rape. The patient’s statements do not reflect somatic symptoms, repression, or projection.

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  • 46. 

    A child with a congenital heart defect is ordered 200 mcg of Digoxin IV QD. The medication is available in a vial of 100 mcg/ml and needs to be diluted with 3 ml of NS. After diluting the medication the concentration available is 25mcg/ml. How much mls is needed for your dose of 200 mcg?

    Correct Answer
    8 mL
    8 ml
    Explanation
    The child needs a dose of 200 mcg of Digoxin. The medication is available in a vial of 100 mcg/ml. To prepare the dose, the medication needs to be diluted with 3 ml of NS. After dilution, the concentration of the medication is 25 mcg/ml. To calculate the amount of medication needed, we can use the equation: (dose needed / concentration available) x diluent volume. Plugging in the values, we get (200 mcg / 25 mcg/ml) x 3 ml = 8 ml. Therefore, 8 ml is needed for the dose of 200 mcg.

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  • 47. 

    A child with an acute infection has an order of Ancef 300 mg IV every 12 hours. The pharmacy prepares this medication for you in a syringe of 300mg/15ml and suggests that it be administered over 30 minutes. Using the rate suggested by pharmacy, what will be the rate set on your syringe pump in ml/hour?

    Correct Answer
    30 mL/hr
    30 ml/hr
    Explanation
    The rate set on the syringe pump will be 30 mL/hr or 30 ml/hr because the pharmacy suggests administering the medication over 30 minutes. Since the medication is prepared in a syringe of 300mg/15ml, it means that each 15ml of the medication contains 300mg. Therefore, to administer the medication over 30 minutes, the rate would be 15ml/30 minutes, which simplifies to 0.5ml/minute. To convert this rate to ml/hour, it would be multiplied by 60 minutes, resulting in 30 ml/hr.

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  • 48. 

    A child with cellulitis is ordered Rocephin 1000 mg IV every 12 hours. The pharmacy prepares this medication for you in a syringe of 1000mg/25ml. The pharmacy suggests the medication be administered over 30 minutes. Using the pharmacy's suggested rate, what will you program your rate in your syringe pump in ml/hour?

    Correct Answer
    50 mL/hr
    Explanation
    The pharmacy suggests administering the medication over 30 minutes. To calculate the rate in ml/hour, we need to convert the 30 minutes to hours. Since there are 60 minutes in an hour, 30 minutes is equal to 0.5 hours.

    The medication syringe contains 1000 mg in 25 ml. Therefore, the concentration of the medication is 1000 mg/25 ml.

    To calculate the rate in ml/hour, we divide the concentration (25 ml) by the time (0.5 hours).

    25 ml / 0.5 hours = 50 ml/hour.

    Therefore, the rate to program in the syringe pump is 50 ml/hour.

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  • 49. 

    A newborn with sepsis is ordered Vancomycin 40mg IV every 12 hours. The pharmacy prepares and delivers a syringe of 40mg/8ml to be administered in 90 minutes. What is your rate that you will set on your syringe pump? (Round to Whole Number)

    Correct Answer
    5 mL/hr
    Explanation
    The rate that you will set on your syringe pump is 5 mL/hr. This is because the syringe contains 40mg of Vancomycin in 8ml, which means there is 5mg of Vancomycin in 1ml. Since the dose ordered is 40mg every 12 hours, you need to administer 40mg over a period of 12 hours, which is 720 minutes. To calculate the rate, you divide the total volume (8ml) by the total time (720 minutes), which gives you a rate of 0.0111 ml/minute. To convert this to mL/hr, you multiply by 60, resulting in a rate of 0.6667 mL/hr. Rounding to the nearest whole number, the rate is 1 mL/hr.

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  • 50. 

    An infant is hospitalized with diarrhea. He has recieved his fluid replacement fluids and now needs to have his fluid maintenance requirements administered in 24 hours. He is currently 9 kg. The formula to calculate his daily fluid requirements is 100mg/kg. How much fluids will he need to receive in 24 hours? What will be the rate you will set his IV pump per ml/hour? (Round to whole number).

    Correct Answer
    900 mL/day, 38 mL/hr
    Explanation
    The infant needs to receive 900 mL of fluids in 24 hours to meet his fluid maintenance requirements. To calculate the rate for the IV pump, we divide the total volume by the number of hours. Therefore, the rate should be set at 38 mL/hour.

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