(3) First concentrate on reading. that it is the most difficult part. Attempt the first test of book 1 "in the manner you want" and do it in 55 minutes and check your score. If you have not completed your test and time has run out, give zero to all wrong answers. Just mark yourself. This is your baseline

General tips

Become familiar with the test as early as possible. The skills being tested in the IELTS take a period of time to build up. Cramming is not an effective study technique. Use your study time efficiently. Study when you are fresh and, after you have planned a timetable, make sure that you keep to it. Set goals and ensure that you have adequate breaks. In the IELTS test, each of the four Band Modules listening, Reading, Writing and speaking carries the same weight. Study each skill carefully and spend more time on the skills in which you feel you are weak.

Be aware of the exact procedure for the test. Be very clear on the order of each section, its length and the specific question types. There are many resources available to help you practice these skills.

Having a study partner or a study group is an excellent idea. Other students may raise issues that you may not have considered.

Seek help from teachers, friends and native English speakers.

This is not a time for intensive study. It is a time to review skills and your test technique. It is important to exercise, eat, rest and sleep well during the week in which you will take the test.

Leave nothing to chance. If you do not know how to get to the test center, try going there at a similar time one or two weeks before the real test.

The night before the test

You must have a good dinner and go to bed at your normal time not too early and not too late, as you do not want to disrupt your sleep pattern if possible. Have everything ready that you need to take with you to the test so you can simply pick it up in the morning, for example, the test registration form, passport, test number, pens, pencils, erasers, etc. A pen that runs dry or a pencil that breaks can take several minutes to replace. Check before the exam exactly what articles you need. Set your alarm clock the night before or arrange a wake-up call.

On the morning of the test

Eat a good breakfast. You will have several hours of concentration ahead of you and you will need food and drink in the morning. You may even want to bring more food or a snack with you, especially if your speaking test is at a later time that day. You cannot, however, take food or drink into the exam room. If possible, wear a watch in case you cannot see the clock in the exam room. It is essential that you keep track of time.

Give yourself plenty of time to get to the test center. You will be required to complete a registration form and to show your passport before you enter the examination room so you must arrive at the time specified by your test center. If you are early, you could go for a walk. If you are late, you will not be allowed to enter. Avoid the added tension of having to rush.

During the test

Most students at the test will feel nervous. This is quite normal. In fact, it can actually be quite helpful in terms of motivation. It may make you alert and help you to focus. The aim is for you to try to perform at your optimum level.

In contrast, high levels of anxiety can affect a student's performance. However, good preparation, familiarity with test details and a positive attitude can overcome much of this anxiety.

The examination room should be suitable for testing, that is, the lighting, ventilation and temperature should be appropriate. If you are uncomfortable because of any of these factors or if there is some other problem, such as not being able to hear the recording of the Listening Module, make sure you ask the person in charge to do something about it. For example, you may ask to change seats.

http://www.aippg.com/ielts/strategies%20for%20ielts.htm

Basic Care and Comfort

August 14, 2008 by schuster27

Basic Care and Comfort
Question 1
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
A) Decreased carbohydrates and fat
B) Decreased sodium and potassium
C) Increased potassium and protein
D) Increased sodium and fluids

Answers Correct B

Review Information: The correct answer is B: Decreased sodium and potassium
Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
McCampbell, L.S. & Rentro, A.R.(2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 2
Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?
A) All 4 side rails up, wheels locked, bed closest to door
B) Lower side rails up, bed facing doorway
C) Knees bent, head slightly elevated, bed in lowest position
D) Bed in lowest position, wheels locked, place bed against wall

Answers Correct D

Review Information: The correct answer is D: Bed in lowest position, wheels locked, place bed against wall
No longer is it advisable to use the lower side rails. With all 4 side rails used it reflects inappropriate use of protective restraints without an order. Placing the bed against the wall permits getting out of bed on only 1 side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest position (without bending limbs to restrict movement) provides a shorter distance to the ground if the client chooses to get out of bed. If the side rails are used 3 pulled up are acceptable. If 4 are pulled up an order for protective restraints is needed and has to usually be renewed in 48 to 72 hours along with more frequent documentation.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 3
Which statement best describes the effects of immobility in children?
A) Immobility prevents the progression of language and fine motor development
B) Immobility in children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults
D) Children are likely to have prolonged immobility with subsequent complications

Answers Correct B

Review Information: The correct answer is B: Immobility in children has similar physical effects to those found in adults
Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.
Ashwill, J., Droske, S. and James, S. (2002). Nursing Care of Children: Principles and Practice. (2nd Edition). Philadelphia: Saunders.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 4
An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client’s gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids

Answers Correct B

Review Information: The correct answer is B: Check the client’s gag reflex
When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 5
A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the client’s report of pain
D) determine the client’s status of pain

Answers Correct C

Review Information: The correct answer is C: Accept the client''s report of pain
Although the information above is correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain --“the client’s report”.
Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 6
The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID
A) Glycerine suppositories
B) Fiber supplements
C) Laxatives
D) Stool softeners

Answers Correct C

Review Information: The correct answer is C: Laxatives
Most elders are constipated because they have used over-the-counter laxatives for a long time. In addition, most do not eat enough fiber, drink enough water, or exercise adequately. Elders are rarely constipated because of organic or pathological reasons.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 7
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort?
A) Increase oral fluid intake
B) Encourage visits from family and friends
C) Keep conversations short
D) Monitor vital signs frequently

Answers Correct C

Review Information: The correct answer is C: Keep conversations short
Keeping conversations short will promote the client’s comfort by decreasing demands on the client’s breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client’s rest. Monitoring vital signs is an important assessment but not related to promoting the client’s comfort.
Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 8
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
A) Abdominal x-ray
B) Auscultation
C) Flushing tube with saline
D) Aspiration for gastric contents

Answers Correct A

Review Information: The correct answer is A: Abdominal x-ray
Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Question 9
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
A) Presence of blood in stools
B) Oozing liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements

Answers Correct B

Review Information: The correct answer is B: Oozing liquid stool
The correct answer it B. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 10
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client

Answers Correct A

Review Information: The correct answer is A: A 79 year-old malnourished client on bed rest
Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 11
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
A) Every four to six hours
B) Continuously
C) In a bolus
D) Every hour

Answers Correct B

Review Information: The correct answer is B: Continuously
Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client''s tolerance to formula.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 12
The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
A) Cheese sandwich with a glass of 2% milk
B) Sliced turkey sandwich and canned pineapple
C) Cheeseburger and baked potato
D) Mushroom pizza and ice cream

Answers Correct B

Review Information: The correct answer is B: Sliced turkey sandwich and canned pineapple
Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All other choices contain one or more high sodium foods.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 13
The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?
A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato

Answers Correct D

Review Information: The correct answer is D: Baked potato
The baked potato contains 610 milligrams of potassium.
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.
Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 14
Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?
A) Obtain a complete blood count
B) Obtain a health and dietary history
C) Refer to a provider for a physical examination
D) Measure height and weight

Answers Correct B

Review Information: The correct answer is B: Obtain a health and dietary history
Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 15
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A) Allow the client to melt ice chips in the mouth
B) Provide mints to freshen the breath
C) Perform frequent oral care with a toothsponge
D) Swab the mouth with glycerin swabs

Answers Correct C

Review Information: The correct answer is C: Perform frequent oral care with a toothsponge
Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 16
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence

Answers Correct C

Review Information: The correct answer is C: Reposition every two hours
Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow is maintained to areas of potential injury.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 17
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
A) Exercise doing weight bearing activities
B) Exercise to reduce weight
C) Avoid exercise activities that increase the risk of fracture
D) Exercise to strengthen muscles and thereby protect bones

Answers Correct A

Review Information: The correct answer is A: Exercise doing weight bearing activities
Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 18
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
A) Assess the severity and location of the pain
B) Obtain an order for an analgesic
C) Reassure him that this is not unusual for his age
D) Encourage him to increase his activity

Answers Correct A

Review Information: The correct answer is A: Assess the severity and location of the pain
Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. There is no real evidence that pain of older adults is less intense than younger adults. It is important for the nurse to assess the pain thoroughly before implementing pain relief measures.
Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 19
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate
A) 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Answers Correct D

Review Information: The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
Ignatavicius, D., and Workman, L., (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia. Saunders
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Question 20
A client with diarrhea should avoid which of the following?
A) Orange juice
B) Tuna
C) Eggs
D) Macaroni

Answers Correct A

Review Information: The correct answer is A: Orange juice
Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.
Beare, P. and Myers, J. (1998) Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.
Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Psychosocial Integrity

August 14, 2008 by schuster27

Psychosocial Integrity
Question 1
An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's response is an example of
A) Discrimination
B) Stereotyping
C) Ethnocentrism
D) Prejudice

Answers Correct D

Review Information: The correct answer is D: Prejudice
Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or situation.
Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 2
A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?
A) The refusal of any treatment for self and the neonate until she talks to a reader
B) The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary
C) Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done
D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."

Answers Correct D

Review Information: The correct answer is D: Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."
Infant baptism is madatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief. Option B is a belief of Russian Orthodoxy. Mormons believe of devine healing with the laying on of hands, as represented in option C.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 3
A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as
A) Perseveration
B) Circumstantiality
C) Neologisms
D) Flight of ideas

Answers Correct D

Review Information: The correct answer is D: Flight of ideas
Flight of ideas is characterized by over productivity of talk and verbal skipping from 1 idea to another. It is classic with clients diagnosed as bipolar disorder and occurs in the manic state of this disease.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.
Varcarolis, E., (2002) Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia. Saunders

Question 4
A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents?
A) Depression
B) Anger
C) Frustration
D) Disbelief

Answers Correct D

Review Information: The correct answer is D: Disbelief
The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depression and acceptance. Each stage can take any amount of time to work through. Clients often go back and forth the stages before acceptance occurs. Some client get stuck in 1 or 2 of the stages.
Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s NursingCare of Infants and Children, (7th ed). St. Louis: Mosby.
Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003) Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Question 5
Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client
A) Has revitalized a relationship with her family to help cope with the death of a daughter
B) Had recognized regressive behavior as a defense mechanism
C) Expresses a desire to be cared for and pampered
D) Recognizes feelings with appropriate expression of feelings

Answers Correct D

Review Information: The correct answer is D: Recognizes feelings with appropriate expression of feelings
During the working phase, the client is able to focus on pleasant or unpleasant feelings and express them appropriately.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 6
A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing
A) Guilt
B) Bloating
C) Anxiety
D) Fear

Answers Correct A

Review Information: The correct answer is A: Guilt
If people with anorexia lose control and eat more than they believe to be appropriate, they experience guilt.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.
Varcarolis, E., (2002) Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia. Saunders

Question 7
Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?
A) "I am determined to leave my house in a week."
B) "No one else in the family has been treated like this."
C) "I have only been married for 2 months."
D) "I have tried leaving, but have always gone back."

Answers Correct D

Review Information: The correct answer is D: "I have tried leaving, but have always gone back."
Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.
Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 8
Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
A) "You look upset. Would you like to talk about it?"
B) "I'd like to know more about your family. Tell me about them."
C) "I understand that you lost your partner. I don't think I could go on if that happened to me."
D) "You look very sad. How long have you been this way?"

Answers Correct A

Review Information: The correct answer is A: "You look upset. Would you like to talk about it?"
Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 9
An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next?
A) Help the student to identify a specific problem
B) Ask the parent to identify the major problem
C) Ask the student to think of different alternatives
D) Examine with the parent a varitey of options

Answers Correct B

Review Information: The correct answer is B: Ask the parent to identify the major problem
If a client is unable to participate in problem solving because of developmental delays or altered mental status, then crisis intervention should not be attempted. However the family can be approached with the use of crisis intervention methods. The crisis intervention method includes 5 steps: identify the problem and then the alternatives, selection of an alternative, implementation, and evaluation.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 10
A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?
A) Ask client if there are any old injuries also present
B) Interview the client without the persons who came with the client
C) Gain client's trust by not being hurried during the intake process
D) Photograph the specific injuries in question

Answers Correct B

Review Information: The correct answer is B: Interview the client without the persons who came with the client
It is critical to separate the client from their partner or significant other. With the use of the nursing process the nurse’s first action when a client is unstable or has potential problems is further assessment of the situation.
Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Uper Saddle River, New Jersey: Prentice Hall.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 11
A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be
A) "These pills aren’t antacids since they are all different."
B) "Some teenagers use pills to lose weight."
C) "Tell me about your week prior to being admitted."
D) "Are you taking pills to change your weight?"

Answers Correct C

Review Information: The correct answer is C: "Tell me about your week prior to being admitted."
This is an open-ended question which is nonjudgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client''s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.
Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s NursingCare of Infants and Children, (7th ed). St. Louis: Mosby.

Question 12
A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states “everyone’s life is in God's hands.” The next action for the nurse to take is to
A) Report the situation to the health care provider
B) Discuss the situation with the client's family
C) Ask the client if talking with a priest would be desired
D) Document the situation on the notes

Answers Correct C

Review Information: The correct answer is C: Ask the client if talking with a priest would be desired
Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health-care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 13
Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?
A) "I think all children should have their heads shaved."
B) "I have been restricted in thought and harmed."
C) "I have powers to get you whatever you wish, no matter the cost."
D) "I think all of my contacts last week have attempted to poison me."

Answers Correct C

Review Information: The correct answer is C: "I have powers to get you whatever you wish, no matter the cost."
Grandiosity is characteristic of a manic episode.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.
Varcarolis, E., (2002) Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia. Saunders

Question 14
A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time?
A) Allow the client to randomly move about the holding area until a hosptial room is available
B) Engage the client in an activity that requires focus and individual effort
C) Isolate the client in a secure room until control is regained by the client
D) Locate a room that has minimal stimulation outside of it for admission process

Answers Correct D

Review Information: The correct answer is D: Locate a room that has minimal stimulation outside of it for admission process
This intervention allows the client with moderate anxiety to have human contact in an environment with minimal stimulation. It also facilitates efficiency in the initial screening and admission process to the emergency department.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.

Question 15
A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach?
A) The results of a standardized tool that measures depression
B) Observation of affect and behavior
C) Inquiry about use of alcohol
D) Family history of emotional problems or mental illness

Answers Correct B

Review Information: The correct answer is B: Observation of affect and behavior
Although it is important to begin an assessment for depression immediately, the assessment should not be aggressive unless the nurse has confirmed the observation of the family member or if there are concerns about the risk of suicide.
Clark, M.J. ( 2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall:Upper Saddle River, New Jersey.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Question 16
An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients?
A) An adolescent who was admitted the day before with acute situational depression
B) A middle aged person who has been on the unit for 72 hours with a dysthymia
C) An elderly person who was admitted 3 hours ago with cycothymia
D) A young adult who was admitted 24 hours ago for detoxification

Answers Correct B

Review Information: The correct answer is B: A middle aged person who has been on the unit for 72 hours with a dysthymia
The findings suggest a client who is depressed. The most therapeutic mileu or environment for this client would be the client with a similar problem and a client that might be more stable. A secondary consideration is to match the age as close as possible. The client in option A has depression and would be more likely to be unstable since they have been in the agency for 24 hours. Dysthymia is defined as a mild depression with findings of trouble falling asleep or no difficulty falling asleep but then wakes up in the middle of the night and with difficulty is able to fall back asleep. Cycothymia is the occurance of periods for behaviors that do not meet the criteria for manic or major depressive episodes.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 17
A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of
A) Prejudice
B) Discrimination
C) Stereotyping
D) Racism

Answers Correct C

Review Information: The correct answer is C: Stereotyping
Stereotyping refers to placing people and institutions, mentally or by attitudes, into a narrow, fixed trait, rigid pattern, or within inflexible "boxlike" characteristics. Stereotyping is one of the most common concerns of nurses when they begin to study different cultures and learn about transcultural nursing.
Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.
Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson Prentice Hall.

Question 18
A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is
A) "I apologize for the delay. I was involved in an emergency."
B) "Let's talk. Why are you upset about this?"
C) "I am surprised that you are upset. The request could have waited a few more minutes."
D) "I see this is frustrating for you. I have a few minutes so let's talk."

Answers Correct D

Review Information: The correct answer is D: "I see this is frustrating for you. I have a few minutes so let''s talk."
This is the best response because it gives credence to the client''s feelings and then concerns. Option B does not acknowledge or validate the client''s feelings.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Varcarolis, E., (2002) Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia. Saunders

Question 19
A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action?
A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist
B) The elders may be with the client during the process of the client dying and no last rites are given
C) The family must be with the client during the process of dying and be the only ones to wash the body after death
D) The body is ritually cleansed and burial is to be as soon as possible after the death occurs

Answers Correct A

Review Information: The correct answer is A: After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client''s wirst
This action indicates a blessing in the practice of Hinduism. The family of a client who has the belief of Hinduism is particular about who touches the dead body and cremation is preferred. Also last rites are carefully prescribed. The actions in option B are expected with persons from the Church of Jesus Christ of Latter Day Saints (also known as Mormon). Also with this belief cremation is discouraged. Option C lists practices of the Islam religion. In addition only the family and friend may touch the body. Option D lists practices of Judaism. In addition autopsy is prohibited and organ donation or transplants are first approved by a rabbi.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 20
During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice?
A) "I wonder who is paying for this trip to the hospital?"
B) "I think she needs to go to the city hospital."
C) "All those people indulge in large families!"
D) "Doesn't she know there's such a thing as birth control?"

Answers Correct D

Review Information: The correct answer is D: "Doesn''t she know there''s such a thing as birth control?"
Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or situation.
Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Health Promotion and Maintenance

August 14, 2008 by schuster27

Health Promotion and Maintenance
Question 1
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water

Answers Correct A

Review Information: The correct answer is A: Formula or breast milk
Formula or breast milk are the perfect food and source of nutrients and liquids up until 1 year.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 2
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
A) Discharge the client from home health care related to noncompliance
B) Notify the health care provider of the client's failure to follow prescribed diet
C) Discuss diet with the client to learn the reasons for not following the diet
D) Make a referral to Meals-on-Wheels

Answers Correct C

Review Information: The correct answer is C: Discuss diet with client to learn the reasons for not following the diet
When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the health care provider, it is best to have a complete understanding of the client''s behavior and feelings as a basis for future teaching and intervention.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 3
While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best?
A) "That's OK, its all right to skip your medication now and then."
B) "I will have to call your doctor and report this."
C) "Is there a reason why you don't want to take your medicine?"
D) "Do you understand the consequences of refusing your prescribed treatment?"

Answers Correct C

Review Information: The correct answer is C: "Is there a reason why you don't want to take your medicine?"
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 4
When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt

Answers Correct D

Review Information: The correct answer is D: During the preadolescent growth spurt
Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 5
The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
A) Focus on the child's needs and recovery
B) Explain the cause of the child's illness
C) Acknowledge that early care would have been better
D) Accept their feelings without judgment

Answers Correct D

Review Information: The correct answer is D: Accept their feelings without judgment
Parents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be accepted.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 6
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client's refusal
D) Ask the client if the preference would be to remove the dentures in the operating room receiving area

Answers Correct D

Review Information: The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 7
The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in games with other children

Answers Correct B

Review Information: The correct answer is B: Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Question 8
An appropriate goal for a client with anxiety would be to
A) Ventilate anxious feelings to the nurse
B) Establish contact with reality
C) Learn self-help techniques
D) Become desensitized to past trauma

Answers Correct C

Review Information: The correct answer is C: Learn self-help techniques
Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 9
A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation

Answers Correct A

Review Information: The correct answer is A: Noncompliance related to medication side effects
The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen from side effects, not a lack of knowledge about the disease process.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 10
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes

Answers Correct D

Review Information: The correct answer is D: Reported behavioral changes
If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
Edelman, C.L. and Mandle, C.M.(2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 11
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child's normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures

Answers Correct B

Review Information: The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern
The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth.
Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 12
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"

Answers Correct A

Review Information: The correct answer is A: Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 13
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers

Answers Correct D

Review Information: The correct answer is D: Playing cooperatively with other preschoolers
Cooperative play is typical of the preschool period.
Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 14
A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic?
A) "Well people often take their own feelings of inadequacy out on others."
B) "I think you’re good. So you see, there’s one person who likes you."
C) "I’m not sure what you mean. Tell me a bit more about that."
D) "Let's discuss this to see the reasons to create this impression on people?"

Answers Correct C

Review Information: The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that."
Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 15
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass

Answers Correct B

Review Information: The correct answer is B: Auscultate the mass
Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the health care provider. The mass should not be palpated because of the risk of rupture.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Question 16
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events
B) Detaching or dissociating in this way postpones painful feelings
C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict
D) To isolate the feelings in this way reduces conflict within the client and with others

Answers Correct A

Review Information: The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events
Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.) Upper Saddle River, NJ: Prentice-Hall.
Varcarolis, E., (2002) Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia. Saunders

Question 17
When teaching a 10 year-old child about their impending heart surgery, which form of explaination meets the developmental needs of this age child?
A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery
C) Introduce the child to another child who had heart surgery 3 days ago
D) Explain the surgery using a model of the heart

Answers Correct D

Review Information: The correct answer is D: Explain the surgery using a model of the heart
According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 18
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the bestreality orientation for this client?
A) "Good morning. Do you remember where you are?"
B) "Hello. My name is Elaine Jones and I am your nurse for today."
C) "How are you today? Remember, you're in the hospital."
D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones."

Answers Correct D

Review Information: The correct answer is D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones."
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregivers name.
Clark, M.J. ( 2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall:Upper Saddle River, New Jersey.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 19
The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23

Answers Correct D

Review Information: The correct answer is D: December 23
Naegele''s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Uper Saddle River, New Jersey: Prentice Hall.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 20
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery

Answers Correct B

Review Information: The correct answer is B: Deep breathing
Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Management of Care

August 14, 2008 by schuster27

Management of Care
Question 1
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?
A) I am sorry. Referral information can only be provided by the client’s health care providers.
B) “I can never give any information out by telephone. How do I know who you are?"
C) Since this is a referral, I can give you this information.
D) I need to get the client’s written consent before I release any information to you.

Answers Correct D

Review Information: The correct answer is D: I need to get the client’s written consent before I release any information to you.
In order to release information about a client there must be a signed consent form with designation of to whom information can be given.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Haynes, L., Boese, T., and Butcher, H. (2004). Nursing in contemporary Society. Upper Saddle River, N.J.: Pearson Prentice Hall.

Question 2
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
A) A 76-year-old client with severe depression
B) A middle-aged client with an obsessive compulsive disorder
C) A adolescent with dehydration and anorexia
D) A young adult who is a heroin addict in withdrawal with hallucinations

Answers Correct B

Review Information: The correct answer is B: A middle-aged client with an obsessive compulsive disorder
The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of instability of condition.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Question 3
After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying
A) "He has a lot of problems. You need to have patience with him."
B) "I will talk with him and try to figure out what to do."
C) "He is scared and taking it out on you. Let's talk to figure out what to do."
D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

Answers Correct C

Review Information: The correct answer is C: "He is scared and taking it out on you. Let''s talk to figure out what to do."
This response explains the client''s behavior without belittling the UAP’s feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 4
The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
A) Encourage oral fluids for the temperature elevation
B) Check temperature 15 minutes after hot liquids are taken
C) Ask the client to drink only cold water and juices
D) Chart this temperature elevation on the flow sheet

Answers Correct B

Review Information: The correct answer is B: Check temperature 15 minutes after hot liquids are taken
Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading. The other options are incorrect.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 5
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?
A) Test a stool specimen for occult blood
B) Assist with the ambulation of a client with a chest tube
C) Irrigate and redress a leg wound
D) Admit a client from the emergency room

Answers Correct C

Review Information: The correct answer is C: Irrigate and redress a leg wound
The PN is a licensed provider and can perform this complex task. Options A and B could be delegated to a UAP and option D requires an RN.
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Question 6
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
A) Normal patterns of behavior may be labeled as deviant, immoral, or insane
B) The meaning of the client's behavior can be derived from conventional wisdom
C) Personal values will guide the interaction between persons from 2 cultures
D) The nurse should rely on her knowledge of different developmental mental stages

Answers Correct A

Review Information: The correct answer is A: Normal patterns of behavior may be labeled as deviant, immoral, or insane
Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 7
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
A) Has had a change in respiratory rate by an increase of 2 breaths
B) Has had a change in heart rate by an increase of 10 beats
C) Was minimally responsive to voice and touch
D) Has had a blood pressure change by a drop in 8 mmHg systolic

Answers Correct C

Review Information: The correct answer is C: Was minimally responsive to voice and touch
A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.
Ashwill, J., Droske, S. and James, S. (2002). Nursing Care of Children: Principles and Practice. (2nd Edition). Philadelphia: Saunders.

Question 8
A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to
A) Keep the client’s room door cracked to minimize the distractions
B) Assign 1 of the nursing staff to visit the client regularly
C) Reassure the client that 1 staff person will check frequently if the client needs anything
D) Arrange for each staff member to go into the client’s room to check on needs every hour on the hour

Answers Correct B

Review Information: The correct answer is B: Assign 1 of the nursing staff to visit the client regularly
Regular, frequent, planned contact by 1 staff member provides continuity of care and reduces the client’s need for attention.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Wywialowski, E. Managing Client Care. St. Louis: Mosby, 2004.

Question 9
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
A) A Dopamine drip IV with vital signs monitored every 5 minutes
B) A myocardial infarction that is free from pain and dysrhythmias
C) A tracheotomy of 24 hours in some respiratory distress
D) A pacemaker inserted this morning with intermittent capture

Answers Correct B

Review Information: The correct answer is B: A myocardial infarction that is free from pain and dysrhythmias
This client is the most stable with minimal risk of complications or instability. The nurse can transfer basic nursing skills to care for this client.
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Question 10
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to
A) Ask to not be assigned to this client or to work on another unit
B) Tell the client that such behavior is inappropriate
C) Inform the client that hospital policy prohibits staff to date clients
D) Discuss the boundaries of the therapeutic relationship with the client

Answers Correct D

Review Information: The correct answer is D: Discuss the boundaries of the relationship with the client
The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby
Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Question 11
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
A) "How long have you been a UAP and what units you have worked on?"
B) "What type of care do you give on the surgical unit and what ages of clients?"
C) "What is your comfort level in caring for children and at what ages?"
D) "Have you reviewed the list of expected skills you might need on this unit?"

Answers Correct D

Review Information: The correct answer is D: "Have you reviewed the list of expected skills you might need on this unit?"
The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to achieve this in the least amount of time.
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Question 12
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that
A) A referral is needed to the psychiatrist who is to provide the client with answers
B) The client has a right to know about the prescribed medications
C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
D) Clients with schizophrenia are at a higher risk of psychosicial complications when they know about their medication side effects

Answers Correct B

Review Information: The correct answer is B: The client has a right to know about the prescribed medications
Clients have a right to informed consent which includes medications, treatments, or diagnositic studies.
Townsend, M. (2003). Psychiatric Mental Health Nursing. Philadelphia: Saunders.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 13
Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client's response to passive range of motion excercises
D) Apply and care for a client's rectal pouch

Answers Correct D

Review Information: The correct answer is D: Apply and care for a client''s rectal pouch
The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine type of task.
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 14
A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first
A) Focus on reality orientation to place and person
B) Assist with the report of the client’s complaint to the police
C) Obtain more details of the client’s claim of abuse
D) Document the statement on the client’s chart with a report to the manager

Answers Correct C

Review Information: The correct answer is C: Obtain more details of the client’s claim of abuse
The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint.
Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 15
The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
A) Assign an RN to provide total care of the client
B) Assign a nursing assistant to help the client with self-care activities
C) Delegate complete care to an unlicensed assistive personnel
D) Supervise a nursing assistant for skin care

Answers Correct D

Review Information: The correct answer is D: Supervise a nursing assistant for skin care.
The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.
Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

Question 16
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
A) To observe the type and amount of nasogastric tube drainage
B) Monitor the client for nausea or other complications
C) Irrigate the nasogastric tube with the ordered irrigant
D) Perform nostril and mouth care

Answers Correct D

Review Information: The correct answer is D: Perform nostril and mouth care
Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation.
Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 17
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
A) "I must document and report any information."
B) "I can’t make such a promise."
C) "That depends on what you tell me."
D) "I must report everything to the treatment team."

Answers Correct B

Review Information: The correct answer is B: "I can’t make such a promise."
Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
Townsend, M. (2003). Psychiatric Mental Health Nursing. Philadelphia: Saunders.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 18
Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."
B) "If the client is dizzy on standing, ask him to take some deep breaths."
C) "Assist the client to the bathroom at least twice on this shift."
D) "After you assist him to the chair, let me know how he feels."

Answers Correct A

Review Information: The correct answer is A: "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."
Give clear information to the UAP about what is expected for client safety.
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Question 19
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?
A) Assist a client post cerebral vascular accident to ambulate
B) Feed a 2 year-old in balanced skeletal traction
C) Care for a client with discharge orders
D) Collect a sputum specimen for acid fast bacillus

Answers Correct C

Review Information: The correct answer is C: Care for a client with discharge orders
The RN is the best person to do teaching or evaluation that is needed at time of discharge.
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Question 20
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Test blood sugar every 2 hours by accucheck
B) Review with family and client signs of hyperglycemia
C) Monitor for mental status changes
D) Check skin condition of lower extremities

Answers Correct A

Review Information: The correct answer is A: Test blood sugar every 2 hours by accucheck
The UAP can do standard unchanging procedures
Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.
Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Nursing Theorist by: saddleup @http://www.scribd.com/doc/2249703/Nursingbulletin-nursing-theories

July 22, 2008 by schuster27

Re: A TRIBUTE TO ACTIVE PNC BLOGGERS

July 19, 2008 by schuster27

wow thanks red sa tribute mo huhuhu nakakaiyak...thanks a lot

slides collections

July 15, 2008 by schuster27

safety and infectious (NCSBN lec)

June 15, 2008 by schuster27

FILE: Lesson 2 Safety & Infection control.doc

[goodnursesclub] CGFNS,NCLEX and CANADA

June 7, 2008 by schuster27

Due to the present retrogression in the US, Canada is another option for Pinoy Nurses.

CGFNS or NCLEX is not needed in Canada but if you already passed both or either one of the two, you have a better chance of getting hired.

Our Consultancy firm Aureus Manpower and Consultancy Corp will conduct orientation tomorrow at 10 am and 2:30 pm exclusively for Pinoy RN. Topic is " Four Different Ways on how to get to Canada "

Pls see this webpage for some referrence

Aureus Consultancy

09228886469

SOCIOCULTURAL FEATURES

June 7, 2008 by schuster27

FILE: SOCIOCULTURAL FEATURES.doc

CULTURAL CONSIDERATIONS

June 7, 2008 by schuster27

FILE: CULTURAL CONSIDERATIONS.doc

nclex files

May 29, 2008 by schuster27

http://www.esnips.com/doc/40442de5-0134-4b05-b596-8a1f756fa5a9/nclex2/?widget=documentIcon">

SATA

May 29, 2008 by schuster27

1. CERVICAL CA
Risk Factors:
• African- American/ Native
women
• Behavior (Sexual promiscuity)
• Chronic instrumentation of cervix
• Disease –STD
• Early age of Sex
• High Parity
• Poor Hygiene
• Low economic status
• Multiple sexual partners
• Partner with Prostate CA
Sx:
• Post-coital bleeding
• Painful sex
• Menstrual irregularities

2. OVARIAN CA
Risk factors:
• Ovarian dysfunction
• Vaginal use of talcum powder
• Alcohol
• Race - White women & family
history
• Infertility
• Age - Peak=5th decade of life
• Nulliparity
• Genetic predisposition

3. DM FOOT CARE
• Meticulous care to feet
• Wash feet with warm water not hot &
dry
• Can use lotion but No lotion in
between toes
• Wear socks to keep feet warm
• Avoid thermal baths, heating pads
• Do not soak feet
• Inspect feet daily
• Do not treat corns, blisters
• Wear loose socks and no barefoot
• Change into clean cotton socks daily
• Break in new shoes gradually
• Use emery board
• Do not smoke
• Do not wear same pair of shoes 2
days in a row
• Check shoes for cracks before using

4. BLOOD TRANSFUSION
REACTION
• Transfusion Reactions
Hemolytic Reaction
Allergic Reaction
• Circulatory Overload
• Septicemia
• Iron Overload
• Hypocalcemia
• Disease Transmission
• Hyperkalemia
• Citrate Intoxication
• Low K, P
• Restrict Na

5. HYPERTHYROIDISM
• Soft smooth skin & hair
• Mood swings
• HPN
• Diaphoresis
• Intolerance to heat
• PTU drug to block thyroid synthesis

6. LUNG CA
• Bronchogenic Carcinoma
• 1st leading cause of death
• From asbestos, bacterial invasion,
cigarette
• Sx: Nagging cough, hoarseness of
voice, dyspnea, diminished breath
sounds

7. SX OF PARKINSONS
• Tremors, akinesia, rigidity
• Weakness, “motorized propulsive
gait
• Slurred speech, dysphagia, drooling
• Monotonous speech
• Mask like expression
• Teach ambulation modification:
goose stepping walk (marching),
ROM exercises
• Meds—Artane, Cogentin, L-Dopa,
Parlodel, Sinemet, Symmetrel
• Activities should be scheduled for
late morning when energy level is
highest
• Encourage finger exercises.
• Promote family understanding of
disease intellect/sight/ hearing not
impaired,

8. ACUTE PANCREATITIS
• Abdominal Pain severe –acute sx
• Complication : Shock,Hypovolemia
• Limited fat & protein intake

9. CAST CARE
Don’t rest on hard surface
Don’t cover until dry 48+ hours
Handle with palms of hands not with
fingers
Keep above level of heart
Check for CSM

10. HYDROCEPHALUS
• Anterior fontanel bulges & nonpulsating
• Bones of head separated (cracked
pot sound)
• Check for sun-setting eyes
• D’ Increase ICP
• Evidence of Frontal Bossing
• Failure to thrive
• Irritability
• High-pitched cry11. ESRD DIET
• Restricted protein intake
• Increase CHO

12. NORMAL IN 8 MONTH OLD
CHILD
- can sit with out support
- can roll from front to back
- can hold a bottle
- closure of ant. fontanel
- can say mama and dada
- 2 teeth present

13. SUPERIOR VENA CAVA OCCLUSION
• Sx occur in the morning
• Edema of face, eyes & tightness of
shirt/ (Stoke’s sign)
• Late sx: edema of arms, hands,
dyspnea, erythema, epistaxis

14. ULCERATIVE COLITIS
Sx:
• Severe diarrhea with blood & mucus
• Abdominal tenderness & cramping
• Anorexia
• Wt. Loss
• Vit. K deficiency
• Anemia
• Dehydration
• Electrolyte imbalance
• Low residue & high protein diet

15. DILANTIN
• do not floss throughout the day
• do not use hard bristled
toothbrush
• Gingivitis S/E
16. ANAPHYLACTIC REACTION
(steps)
• Stop medication
• Maintain airway
• Notify MD
• Maintain IV access of 0.9 NSS
• Place in supine position with legs
elevated
• Monitor VS
• Administer prescribed
emergency drugs
17. BLADDER CA
Risk Factors:
• Hx of smoking
• Exposure to radiation
• Working in industrial Factory
18. S/S OF DKA
• Fruity breath Odor
• Oliguria
• Kusmaull'’s (deep & nonlabored)

19. SITE FOR IM INJECTION ADULT
• Deltoid
• Ventrogluteal
• Vastus Lateralis
• Gluteus Maximus

20. S/S OF BACTERIAL MENINGITIS
• N & V
• Seizures
• Stiff Neck
• Photophobia
• Moon face
• Truncal obesity
• Decreased resistance to infection
• Low Carbohydrate, Low Calorie,
High Protein, High K, Low sodium
• Monitor glucose level
• Check for color of stool, cortisol
increase secretion of gastric acid
– Peptic ulcer & GI bleeding
• C/I to Aspirin, increased bleeding

21. TB
• Waking up sweating at night
• Low grade fever
• Dull aching chest pain
• Cough streaked with blood
• Weight loss
• Anorexia
• Fatigue

22. LIVER CIRRHOSIS
• N & V
• Edema
• Ascites

23. PULMONARY EMBOLISM
Sx:
• Blood-tinged sputum
• Distended neck vein
• Chest Pain / Hypotension /
Cyanosis
• Cough / Shallow respirations
• Rales on auscultation
• Tachypnea / Tachycardia
24. COLON CA
Risk Factors:
• Family HX
• Age above 50
• Jewish
• Male

25. DIGOXIN THERAPY
• Do not administer in infants if <
90 bpm
• Do not give to older children if
<70 bpm
• Sx of toxicity to a child – N &V

26. S/S OF CAD
• Chest Pain
• Palpitations
• Dyspnea / Syncope
• Hemoptysis
• Excessive Fatigue

27. COPD
• Rhythmic, diaphragmatic
breathing
• If restless, perform purse-lip
breathing not more than 1
minute
• Perform deep breathing with
mouth held together during
expiration

28. SEEN IN 15 MONTH OLD CHILD
• Speaks 6 words
• Sits w/o support
• Builds a tower of 5 blocks
• Strong palmar grasp

29. CUSHING’S SYNDROME
• Osteoporosis
• Muscle wasting
• Hypertension
• Purple skin striations
• Severe abdominal pain
• Maternal shock
• Fetal distress

30. ADDISONS DISEASE
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium
High protein, carbohydrate, Sodium,
Low potassium diet
Teach life-long hormone replacement
• Glucocorticoids (sugar) - Solu-
Medrol (succinate) to prevent
addisonian crisis
• Mineralocorticoids (salt) –
Florinef
6 A's of Addison's disease
1.) Avoid Stress
2.) Avoid Strenuous
3.) Avoid Individuals with Infection
4.) Avoid OTC meds
5.) A lifelong Glucocorticoids Therapy
6.) Always wear medic alert bracelet

Addisonian Crisis
• Hypotension
• Extreme weakness
• Nausea vomiting
• Abdominal pain /
• Severe hypoglycemia
• Dehydration
• Administer NaCl IV, vasopressors,
hydrocortisone
• Monitor VS /Absolute bedrest

31. PLACENTA PREVIA
• Check Hematocrit level
• External fetal monitor not internal
• No vaginal examination
• Assess for bleeding
• Improperly implanted placenta at
lower uterine
• Painless bright red, vaginal
bleeding
• Soft, relaxed, nontender uterus
• Fundal height greater than

32. ABRUPTIO PLACENTA
• Premature separation of
placenta from uterine wall
• Painful dark red bleeding
• Uterine rigidity
• Perspiration
• Weakness / dizziness
• Borborygmi sound

33. HEMODIALYSIS
• Palpate for a bruit or thrill
• Weigh client daily, before, during
& after
• Hold antihypertensive drugs b4
dialysis
• Check for thrill and bruit q 8 hours
• Don’t use extremity for BP, finger
stick
• Monitor vital signs, weight, breath
sounds
• Monitor for hemorrhage

34. PERITONEAL DIALYSIS
• Weight before and after treatment
• Monitor BP
• Monitor breath sounds
• Use sterile technique
• If problem w/ outflow, reposition
client
• Side effects: constipation

35. TYPE 1 IDDM
• Test blood glucose every 4 hrs if
no feeling well
• Eat fruit or cheese sandwich
before exercise
• Do not exercise if blood glucose
is >250mg/dl & urinary ketones
present
• Administer regular insulin 30
minutes before meals

36. COMPARTMENT SYNDROME
• Increased pain & swelling
• Pain with passive motion
• Loss of sensation
• Inability to move joints
• Pulselessness

37. CARDIAC CATHETERIZATION
• NPO 6-8 hrs. & no liquid for 4
hrs. prior to prevent vomiting &
aspiration
• Feel a flush, warm, fluttery
feeling, desire to cough,
palpitations in introduction of dye
• Shave & Clean insertion site with
antiseptic solution

38. PERNICIOUS ANEMIA
• Severe pallor
• Smooth, beefy red tongue
• Slight jaundice
• Paresthisias of hands & feet
• Disturbances with gait & balance

39. DUMPING SYNDROME
• Occurs 30 minutes after eating
• Abdominal fullness & cramping
• Diarrhea
• Tachycardia
expected
• Family Hx
• Obesity
• Smoking
• Men

40. TPN COMPLICATIONS
• Air Embolism
• Fluid Overload
• Hyperglycemia
• Hypoglycemia
• Infection
• Pneumothorax

41. DIC
• Bruising, purpura
• Presence of occult blood
• Low fibrinogen level, hct, platelet
• Increased PT, PTT
• Complication: RENAL FAILURE

42. PERIPHERAL ARTERIAL DISEASE
• Dry scaly skin on lower
extremities
• Rest Pain, at night
• Intermittent claudication/
• Thickened toenails
• Cold & gray-blue color of skin
• Decreased or absent peripheral
pulses
• Instruct pt. to walk to point of
claudication, stop & rest & walk
a little farther

43. THROMBOPHLEBITIS
• Avoid pressure behind legs
• Avoid prolonged sitting
• Avoid constrictive clothing
• Avoid crossing the legs
• Avoid massaging the legs

44. SYPHILIS
Painless chancre
fades after 6 weeks
Low grade fever
Copper-colored rash on palms and
soles of feet
Spread by contact of mucous
membranes
Treat with Penicillin G IM
If patient has penicillin allergy, will
use erythromycin for 10-15 days.
After treatment, patient must be
retested to make sure disease is gone

45. POLYCYTHEMIA VERA
• Increased RBC
• Leukocytosis / Thrombocytosis
• Angina
• Intermittent claudication
• Dyspnea /HPN
• Lethargy / Syncope / Paresthesia

46. PRIMARY HPN
Risk Factors:
• Aging
• Black race
• Chronic stress

47. CHOLECYSTITIS
Sx:
• N & V
• Belching
• Indigestion
• Flatulence
• Epigastric pain that radiates to the
scapula 2 hrs. after eating fatty food
• Pain localized in RLQ
• Guarding, rigidity & rebound
tenderness
• Cannot take a deep breath when
fingers are pressed below hepatic
margin (Murphy’s Sign)

Welcome Message to New Members

May 24, 2008 by schuster27

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Thanks for joining PNC forum.

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