Essentials Of Psychiatric Mental Health Nursing

1. The physician orders Acetaminophen 200 mg PO now for a child with a fever. The therapeutic range for acetaminophen is 10-15 mg/kg/dose. The child weighs 26 lbs. Is this a therapeutic dose for this child/ (Answer only yes or no).

The given dose of Acetaminophen (200 mg) is not within the therapeutic range for this child. The therapeutic range for Acetaminophen is 10-15 mg/kg/dose, and the weight of the child is given in pounds (26 lbs), not in kilograms. Therefore, without converting the weight to kilograms, we cannot accurately determine if the dose is within the therapeutic range.

Explanation

The given dose of Acetaminophen (200 mg) is not within the therapeutic range for this child. The therapeutic range for Acetaminophen is 10-15 mg/kg/dose, and the weight of the child is given in pounds (26 lbs), not in kilograms. Therefore, without converting the weight to kilograms, we cannot accurately determine if the dose is within the therapeutic range.

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2. The doctor orders Tobramycin 100 mg IV q 8 hours for a child admitted with an acute infection. The child weighs 44 lbs. The therapeutic range for Tobramycin is 6-7.5 mg/kg/day divided into 3 doses. Is this a therapeutic dose for this child? (Answer only yes or no)

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Explanation

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3. What is a nurse's legal responsibility if child abuse or neglect is suspected?

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

Report the suspected abuse or neglect according to state regulations.

Document the observations and speculations in the medical record.

Continue the assessment.

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.

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.

4. Which family scenario presents the greatest risk for family violence?

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

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

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.

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.

5. 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?

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

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

Insomnia related to cognitive impairment as evidenced by wandering at night

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

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.

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.

6. 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?

Insufficient data are present to make an assessment.

The child and siblings are experiencing neglect.

The children are at high risk for sexual abuse.

The children are experiencing physical abuse

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.

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.

7. 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?

Anorexia nervosa

Bulimia nervosa

Binge eating

Eating disorder not otherwise specified

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.

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.

8. The parent of a 4-year-old says that the child is in constant motion. The parent tries to interest the child in toys, but the child is easily distracted, doesn't listen, and talks constantly. The child gets out of bed earlier than the parent every morning and has caused damage to expensive family possessions. The child was enrolled in preschool, but the teacher could not handle the behavior. The child's problem is most consistent with the DSM-IV-TR criteria for:

Pervasive developmental disorder.

Mental retardation.

Oppositional defiant disorder.

Attention deficit hyperactivity disorder.

ANS: D
The excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest the other possible choices. Developmental delays would be seen if pervasive developmental disorder or mental retardation were present. Oppositional defiant disorder would include serious violations of the rights of others.

Explanation

ANS: D
The excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest the other possible choices. Developmental delays would be seen if pervasive developmental disorder or mental retardation were present. Oppositional defiant disorder would include serious violations of the rights of others.

9. 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?

“I’m fat and ugly.”

“What I think about myself is my business.”

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

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

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.

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.

10. 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:

Is attempting to obtain attention by manipulating staff.

May have sustained a head injury before admission.

Is having a recurrence of an acute psychosis.

Has symptoms of alcohol withdrawal delirium.

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.

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.

11. 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.

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

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

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.

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.

12. Which child shows behaviors indicative of mental illness?

A 3-month-old who cries after feeding until burped and sucks a thumb

A 6-month-old who does not eat vegetables well and likes to be rocked

A 3-year-old who is mute, passive toward adults, and twirls while walking

A 4-year-old who lisps and became enuretic after the birth of a sibling

ANS: C
Symptoms consistent with pervasive developmental disorder are evident in the answer. The behaviors of the other children are within normal ranges.

Explanation

ANS: C
Symptoms consistent with pervasive developmental disorder are evident in the answer. The behaviors of the other children are within normal ranges.

13. 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?

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

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

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

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

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.

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.

14. The parent of a child with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate?

“Perhaps your child was misdiagnosed.”

“Your observation indicates the medication is effective.”

“Tics often change frequency or severity. That doesn’t mean they aren’t real.”

“This finding indicates a worsening of the condition. Let’s review how you’ve been administering the child’s medication.”

ANS: C
Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette’s disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

Explanation

ANS: C
Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette’s disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

15. 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?

Substance abuse

Substance intoxication

Substance dependence

Recreational use of a social drug

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.

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.

16. 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?

Accepting responsibility for medication errors.

High sociability with peers.

Seeking to be assigned as medication nurse.

Presenting a neat physical appearance.

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.

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.

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

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

A monoamine oxidase inhibitor, such as phenelzine (Nardil)

A narcotic analgesic, such as codeine

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.

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.

18. 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:

“Do you often feel fat?”

“Who plans the family meals?”

“What do you eat in a typical day?”

“What do you think about your present weight?”

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.

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.

19. 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?

Check the patient every 15 minutes.

Provide one-on-one supervision.

Keep the room dimly lit.

Rigorously encourage fluid intake.

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.

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.

20. 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?

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

Deficient knowledge related to interpersonal skills with parents

Noncompliance: school attendance related to parental rules

Disturbed personal identity related to negative self-evaluation

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.

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.

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

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.

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.

22. 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?

Disturbed body image related to weight loss

Anxiety related to fear of weight gain

Ineffective coping related to lack of conflict resolution skills

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

ANS: D
The physical assessment by the nurse revealed cachexia; thus the diagnosis of Imbalanced nutrition. No defining characteristics support the other diagnoses.

Explanation

ANS: D
The physical assessment by the nurse revealed cachexia; thus the diagnosis of Imbalanced nutrition. No defining characteristics support the other diagnoses.

23. 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?

Social isolation related to lack of community support system

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

Deficient knowledge related to resources for escape from the abusive relationship

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

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.

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.

24. A child with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?

Central nervous system stimulants

Monoamine oxidase inhibitors (MAOIs)

Antipsychotic medications

Anxiolytic medications

ANS: A
Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

Explanation

ANS: A
Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

25. 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?

Encourage the patient to drink plenty of liquids.

Obtain a clean-catch urine sample.

Place the patient in a vest-type restraint.

Consult the health care provider.

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.

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.

26. 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?

Somatic reaction

Denial

Repression

Projection

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.

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.

27. A 5-year-old with ADHD bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action?

Call for emergency assistance from other staff.

Direct the child to stop, and then comfort the other child.

Instruct the parents to take the child home immediately.

Take the child to another room with toys to act out feelings.

ANS: D
Use of play to express feelings is appropriate because the cognitive and language abilities of the child may require acting out of feelings if verbal expression is limited. The remaining options provide no outlet for feelings or opportunity to develop coping skills.

Explanation

ANS: D
Use of play to express feelings is appropriate because the cognitive and language abilities of the child may require acting out of feelings if verbal expression is limited. The remaining options provide no outlet for feelings or opportunity to develop coping skills.

28. 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?

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.

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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29. 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?

Tension-building

Acute battering

Honeymoon

Recovery

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.

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.

30. 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:

Name two community resources that can be contacted.

Demonstrate insight into the abusive relationship.

Limit contact with the perpetrator by a restraining order.

Facilitate counseling for the perpetrator.

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.

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.

31. A young adolescent is suspected to have Asperger's syndrome. Which assessment finding would support this diagnosis?

Absence of verbal language

Presence of tics and twitching

Severe developmental delays

Limited social skills and empathy

ANS: D
Most children with Asperger’s syndrome manifest poor social skills and problems empathizing with others as their major behavioral symptoms. Verbal skills are rarely impaired. Tics and twitching are more often a part of the clinical picture of Tourette’s syndrome. Severe developmental delays are part of the clinical picture of autism rather than Asperger’s syndrome.

Explanation

ANS: D
Most children with Asperger’s syndrome manifest poor social skills and problems empathizing with others as their major behavioral symptoms. Verbal skills are rarely impaired. Tics and twitching are more often a part of the clinical picture of Tourette’s syndrome. Severe developmental delays are part of the clinical picture of autism rather than Asperger’s syndrome.

32. 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?

Conveying understanding that pressures experienced in nursing underlie substance use.

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

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

Providing health teaching about stress management.

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.

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.

33. 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?

Dilated pupils, tachycardia, elevated blood pressure, elation

Mood lability, incoordination, fever, drowsiness

Nausea, vomiting, diaphoresis, anxiety, tremors

Excessive eating, constipation, headache

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.

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.

34. An infant has just been born with a myelomeningocele. The infant has been admitted to the neonatal intensive care unit. Upon noticing the nursing tech preparing an open crib for this infant, the nurse should:

Not say anything; the tech is doing an appropriate action.

Stop the tech and ask her to prepare a warmer for this infant.

Remind the tech to include adequate warm blankets in the crib.

Ask the tech to place a hat and warm gown for the infant in the crib.

An infant with a myelomeningocele has a vertebral defect that can cause loss of body temperature and also difficulty in thermoregulation. It would not be appropriate to place the infant in a crib.

Explanation

An infant with a myelomeningocele has a vertebral defect that can cause loss of body temperature and also difficulty in thermoregulation. It would not be appropriate to place the infant in a crib.

35. 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?

Chronic low self-esteem

Situational low self-esteem

Ineffective health maintenance

Disturbed personal identity

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.

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.

36. A 44 lb child must receive streptomycin sulfate, 30mg/kg/day in divided doses every 12 hours. The drug is available in 1 gram vials that can be diluted to a concentration of 1 gram/ml. What volume of the drug should the nurse administer at each dose? (Answer to the first decimal point).

The child weighs 44 lb, which is approximately 20 kg. The prescribed dosage is 30 mg/kg/day. Therefore, the child should receive 600 mg (30 mg/kg x 20 kg) of streptomycin sulfate per day. Since the drug is available in 1 gram vials, which can be diluted to a concentration of 1 gram/ml, the nurse should administer 0.6 ml (600 mg = 0.6 ml) of the drug at each dose. Rounded to the first decimal point, the volume of the drug to be administered at each dose is 0.3 mL.

Explanation

The child weighs 44 lb, which is approximately 20 kg. The prescribed dosage is 30 mg/kg/day. Therefore, the child should receive 600 mg (30 mg/kg x 20 kg) of streptomycin sulfate per day. Since the drug is available in 1 gram vials, which can be diluted to a concentration of 1 gram/ml, the nurse should administer 0.6 ml (600 mg = 0.6 ml) of the drug at each dose. Rounded to the first decimal point, the volume of the drug to be administered at each dose is 0.3 mL.

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37. An 11-year-old diagnosed with oppositional defiant disorder becomes angry and defiant over the rules at a residential treatment program and begins shouting at the nurse. What might be the best method to defuse the situation?

Suggest the child go to the gym and shoot baskets.

Place the child in a basket-hold.

Call staff to seclude the child.

Administer an anxiolytic medication.

ANS: A
Redirecting the expression of feelings into nondestructive age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures.

Explanation

ANS: A
Redirecting the expression of feelings into nondestructive age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures.

38. The doctor orders Vancomycin 10mg/kg every 12 hours IV for a newborn with sepsis. The newborn weighs 4000 grams. The medication is supplied in a vial of 500mg/5ml. How much volume should the infant receive per dose?

The doctor has ordered Vancomycin at a dosage of 10mg/kg for the newborn. The newborn weighs 4000 grams, which is equivalent to 4 kg. Therefore, the total dosage of Vancomycin for each dose would be 10mg/kg x 4kg = 40mg.

The medication is supplied in a vial of 500mg/5ml. To calculate the volume needed for the dose, we can set up a proportion:

40mg / x mL = 500mg / 5ml

Cross-multiplying, we get:

40mg * 5ml = 500mg * x mL

200mg = 500mg * x mL

Dividing both sides by 500mg, we find:

x mL = 200mg / 500mg

Simplifying, we get:

x mL = 0.4 mL

Therefore, the infant should receive 0.4 mL per dose of Vancomycin.

Explanation

The doctor has ordered Vancomycin at a dosage of 10mg/kg for the newborn. The newborn weighs 4000 grams, which is equivalent to 4 kg. Therefore, the total dosage of Vancomycin for each dose would be 10mg/kg x 4kg = 40mg.

The medication is supplied in a vial of 500mg/5ml. To calculate the volume needed for the dose, we can set up a proportion:

40mg / x mL = 500mg / 5ml

Cross-multiplying, we get:

40mg * 5ml = 500mg * x mL

200mg = 500mg * x mL

Dividing both sides by 500mg, we find:

x mL = 200mg / 500mg

Simplifying, we get:

x mL = 0.4 mL

Therefore, the infant should receive 0.4 mL per dose of Vancomycin.

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39. 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?

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.

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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40. 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?

Teach stress reduction techniques such as relaxation and imagery.

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

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

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

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.

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.

41. 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?

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

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

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

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.

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.

42. 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?

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.

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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43. Which is an important nursing intervention when caring for an infant with a myelomeningocele in the preop stage?

Place infant supine to decrease pressure on the sac.

Apply a heat lamp to facilitate drying and toughening of the sac.

Measure head circumference daily to identify developing hydrocephalus

Apply a diaper to prevent contamination of the sac.

The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily.

Explanation

The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily.

44. Nursing physical assessment of a patient with bulimia often reveals:

Prominent parotid glands.

Peripheral edema.

Thin, brittle hair.

Amenorrhea.

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.

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.

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

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

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

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

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

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.

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.

46. A child with ADHD has the nursing diagnosis Delayed growth and development related to altered brain executive function as evidenced by hyperactivity, distractibility, and impaired play. The plan of care includes administration of methylphenidate (Concerta). The desired goal for which the nurse should monitor is:

Increased expressiveness in communication with others.

Improved ability to participate in play with other children.

Ability to identify anxiety and implement self-control strategies.

Improved socialization skills with other children and authority figures.

ANS: B
The goal should be directly related to the defining characteristics of the nursing diagnosis; in this case, improvement in the child’s hyperactivity, distractibility, and play. The remaining options are more relevant for a child with pervasive developmental disorder or anxiety disorder.

Explanation

ANS: B
The goal should be directly related to the defining characteristics of the nursing diagnosis; in this case, improvement in the child’s hyperactivity, distractibility, and play. The remaining options are more relevant for a child with pervasive developmental disorder or anxiety disorder.

47. Shortly after a 15-year-old's parents announced that they were divorcing, the adolescent stopped participating in sports, sat alone at lunch, avoided former friends, and stayed in a bedroom while at home. The adolescent told the school nurse, "All the other kids have families. If my parents loved me, they would work out their problems." What nursing diagnosis is most applicable?

Decisional conflict

Social isolation

Chronic low self-esteem

Disturbed personal identity

ANS: B
This diagnosis refers to aloneness that the patient perceives negatively, even when self-imposed. Defining characteristics that the teen displays include expressing feelings of being different from others and self-imposed isolation from peers and family. The other options are not supported by data in the scenario.

Explanation

ANS: B
This diagnosis refers to aloneness that the patient perceives negatively, even when self-imposed. Defining characteristics that the teen displays include expressing feelings of being different from others and self-imposed isolation from peers and family. The other options are not supported by data in the scenario.

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

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

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

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

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

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.

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.

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

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

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.

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.

50. A child has been diagnosed with epilepsy, and is on daily phenytoin (Dilantin). Which client education should the nurse include?

Fluid intake

Good dental hygiene

A decrease in vitamin D intake

Taking the medication with milk

Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged.

Explanation

Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged.

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

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

Calorie intake within required parameters of treatment plan

Weight at established normal range for the patient

Patient satisfaction with body appearance

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.

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.

52. 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?

Sleep patterns

School activities

Losses

Menstrual flow

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.

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.

53. 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:

Primary.

Secondary.

Tertiary.

Prevention is not possible.

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.

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.

54. A nurse notes a blue sclera during a newborn assessment. The infant should be checked for:

Marfan syndrome.

Achondroplasia.

Osteogenesis imperfecta.

Muscular dystrophy.

Clinical manifestations of osteogenesis imperfecta include a blue sclera.

Explanation

Clinical manifestations of osteogenesis imperfecta include a blue sclera.

55. A 3-year-old cries and screams from the time the parents leave the child at preschool to the time of pick-up 4 hours later. The child is calm and relaxed when with the parents. The parents ask their neighbor, a nurse, "What should we do?" What is the nurse's best advice?

“Send a picture of yourself to school to keep with the child.”

“Arrange with the teacher to let the child call home at playtime.”

“Talk with the school about withdrawing the child until maturity increases.”

“Talk with your health care provider about a referral to a mental health clinic.”

ANS: D
Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often the first time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child’s fear that something will happen to the attachment figure. The other options are “short-term” fixes.” The child needs professional help.

Explanation

ANS: D
Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often the first time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child’s fear that something will happen to the attachment figure. The other options are “short-term” fixes.” The child needs professional help.

56. 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.)

“Tell me how you punish your children.”

“How do you stop your baby’s crying?”

“Caring for four small children must be difficult.”

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

“Calling children stupid injures their self-esteem.”

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.

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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57. Calculate the fluid maintenance for a child weighing 26 kg using the formula below 1500ml + (20ml/kg for weight above 20 kg) What is the hourly rate of administration of the fluids? (Round to whole number)

The hourly rate of administration of the fluids is 68 mL/hr. This is calculated by dividing the total amount of fluids (1620 mL/kg/24 hr) by 24 hours.

Explanation

The hourly rate of administration of the fluids is 68 mL/hr. This is calculated by dividing the total amount of fluids (1620 mL/kg/24 hr) by 24 hours.

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58. 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.)

“Tell me how you punish your children.”

“How do you stop your baby’s crying?”

“Caring for four small children must be difficult.”

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

“Calling children stupid injures their self-esteem.”

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.

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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59. 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)

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.

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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60. 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).

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.

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

Advising the patient to accept residential treatment if relapse occurs

Assisting the patient to identify life skills needed for effective coping

Rehearsing techniques to handle anticipated stressful situations

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

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

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.

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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62. 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.)

Keeping a cell phone fully charged

Hiding money with which to buy new clothes

Having the phone number for the nearest shelter

Taking enough toys to amuse the children for 2 days

Securing a supply of current medications for self and children

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

Assembling birth certificates, Social Security cards, and licenses

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.

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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63. 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?

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

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

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

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

ANS: D
The fourth statement is the only strategy that attempts to question the patient’s distorted thinking.

Explanation

ANS: D
The fourth statement is the only strategy that attempts to question the patient’s distorted thinking.

64. What are the primary distinguishing factors between the behavior of children with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? More than one answer is correct.) The child with:

ODD tests limits and disobeys authority figures.

CD often violates the rights of others

ODD relives traumatic events by acting them out.

CD uses stereotypical or repetitive language.

ODD has difficulty separating from the parents.

ANS: A, B
Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with conduct disorder frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are seen in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder.

Explanation

ANS: A, B
Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with conduct disorder frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are seen in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder.

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65. 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.)

Read labels of all liquid medications.

Avoid aged cheeses.

Avoid alcohol-based skin products.

Wear sunscreen and avoid bright sunlight.

Maintain an adequate dietary intake of sodium.

Refrain from eating foods prepared with alcohol.

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

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.

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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66. A school health nurse is screening for scoliosis. For what assessment findings would the nurse look? Select all that apply.

Uneven shoulders and hips

A one-sided rib hump

Prominent scapula

Lordosis

Pain

The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Explanation

The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

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67. A nurse prepares the plan of care for a 15-year-old with moderate mental retardation. What are the highest outcomes that are realistic for this patient? (More than one answer is correct.) Within 5 years, the patient will:

Complete high school or GED.

Live unaided in an apartment.

Independently perform own personal hygiene.

Obtain employment in a local sheltered workshop.

Correctly use public buses to travel in the community.

ANS: C, D, E
Individuals with moderate mental retardation progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or
semiskilled work. With supervision, the person can function in the community but independent living is not likely.

Explanation

ANS: C, D, E
Individuals with moderate mental retardation progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or
semiskilled work. With supervision, the person can function in the community but independent living is not likely.

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68. 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.)

Anger management counseling for the father

Placing the children in a children’s shelter

Continuing home visits to give support

Group sessions to teach childrearing practices

A safety plan for the wife and children

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.

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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69. 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.)

Peripheral edema

Parotid swelling

Constipation

Hypotension

Dental caries

Lanugo

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.

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

Flexible mealtimes

Adherence to a selected menu

Observation during and after meals

Unscheduled weight checks

Monitoring during bathroom trips

Privileges correlated with affective display

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.

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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71. 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.)

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

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

It makes pertinent information available to other care providers.

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

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

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.

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

Administration of naloxone (Narcan)

Vitamin B12 and folate supplements

Restoring nutritional integrity

Reduction of fever

Prevention of seizures

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.

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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