review 16.

A client who had cataract surgery should taught to call his MD

if he has eye pain.

17. Risk for Injury takes priority for a client with Meniere’s

disease.

Below are the nursing bullets for Medical-Surgical Nursing. 18. Irrigate the eye with sterile saline is the priority nursing
intervention when the client has a foreign body protruding from
1. Bone scan is done by injecting radioisotope per IV and then x- the eye.
rays are taken.
19. Snellen’s Test assesses visual acuity.
2. To prevent edema on the site of sprain, apply cold compress on
the area for the first 24 hours. 20. Presbyopia is an eye disorder characterized by lessening of the
effective powers of accommodation.
3. To turn the client after lumbar Laminectomy, use the logrolling
technique. 21. The primary problem in cataract is blurring of vision.

4. Carpal tunnel syndrome occurs due to the injury of median 22. The primary reason for performing iridectomy after cataract
nerve. extraction is to prevent secondary glaucoma.

5. Massaging the back of the head is specifically important for the 23. In acute glaucoma, the obstruction of the flow of
client with Crutchfield tong. aqueous humor is caused by displacement of the iris.

6. A one-year-old child has a fracture of the left femur. He is 24. Glaucoma is characterized by irreversible blindness.
placed in Bryant’s traction. The reason for elevation of his both
legs at 90º angle is his weight isn’t adequate to provide sufficient 25. Hyperopia is corrected by convex lens.
countertraction, so his entire body must be used.
26. Pterygium is caused primarily by exposure to dust.
7. Swing-through crutch gait is done by advancing both crutches
together and the client moves both legs past the level of the 27. A sterile chronic granulomatous inflammation of the
crutches. meibomian gland is chalazion.

8. The appropriate nursing measure to prevent displacement of 28. The surgical procedure which involves removal of the eyeball
the prosthesis after a right total hip replacement for arthritis is to is enucleation.
place the patient in the position of right leg abducted.
29. Romberg’s test is a test for balance or gait.
9. Pain on non-use of joints, subcutaneous nodules and elevated
ESR are characteristic manifestations of rheumatoid arthritis. 30. If the client with increased ICP demonstrates decorticate
posturing, observe for flexion of elbows, extension of the knees,
10. Teaching program of a patient with SLE should include plantar flexion of the feet.
emphasis on walking in shaded area.
31. The nursing diagnosis that would have the highest priority in
11. Otosclerosis is characterized by replacement of the care of the client who has become comatose following
normal bones by spongy and highly vascularized bones. cerebral hemorrhage is Ineffective Airway Clearance.

Eyes and Ears 32. The initial nursing action—for a client who is in the clonic
phase of a tonic-clonic seizure—is to obtain equipment for
orotracheal suctioning.

33. The first nursing intervention in a quadriplegic client who is

12. Use of high-pitched voice is inappropriate for the client with
experiencing autonomic dysreflexia is to elevate his head as high
hearing impairment.
as possible.
13. Rinne’s test compares air conduction with bone conduction.
34. Following surgery for a brain tumor near the hypothalamus,
14. Vertigo is the most characteristic manifestation of Meniere’s the nursing assessment should include observing for inability to
disease. regulate body temp.

15. Low sodium is the diet for a client with Meniere’s disease. ADVERTISEMENTS

[Link]-myelography (using metrizamide (Omnipaque) care Diet and Nutrition
includes keeping head elevated for at least 8 hours.

36. Homonymous hemianopsia is described by a client had CVA

and can only see the nasal visual field on one side and the 53. Most of the absorption of water occurs in the large intestine.
temporal portion on the opposite side.
54. Most nutrients are absorbed in the small intestine.
37. Ticlopidine may be prescribed to prevent thromboembolic
CVA. 55. When assessing a patient’s eating habits, the nurse should ask,
“What have you eaten in the last 24 hours?”
38. To maintain airway patency during a stroke in evolution, have
orotracheal suction available at all times. 56. A vegan diet should include an abundant supply of fiber.

39. For a client with CVA, the gag reflex must return before the 57. A hypotonic enema softens the feces, distends the colon, and
client is fed. stimulates peristalsis.

40. Clear fluids draining from the nose of a client who had a head 58. First-morning urine provides the best sample to
trauma 3 hours ago may indicate basilar skull fracture. measure glucose, ketone, pH, and specific gravity values.

41. An adverse effect of gingival hyperplasia may occur 59. To induce sleep, the first step is to minimize environmental
during Phenytoin (DIlantin) therapy. stimuli.

42. Urine output increased: best shows that the mannitol is 60. Before moving a patient, the nurse should assess the patient’s
effective in a client with increased ICP. physical abilities and ability to understand instructions as well as
the amount of strength required to move the patient.
43. A client with C6 spinal injury would most likely have the
symptom of quadriplegia. 61. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his
weekly intake by 3,500 calories (approximately 500 calories daily).
44. Falls are the leading cause of injury in elderly people. To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly
caloric intake by 7,000 calories (approximately 1,000 calories
45. The client is for EEG this morning. Prepare him for the
daily).
procedure by rendering hair shampoo, excluding caffeine from his
meal and instructing the client to remain still during the 62. To avoid shearing force injury, a patient who is completely
procedure. immobile is lifted on a sheet.

46. Primary prevention is true prevention. Examples are 63. To insert a catheter from the nose through the trachea for
immunizations, weight control, and smoking cessation. suction, the nurse should ask the patient to swallow.

47. Secondary prevention is early detection. Examples include 64. Vitamin C is needed for collagen production.
purified protein derivative (PPD), breast self-examination,
testicular self-examination, and chest X-ray. 65. Bananas, citrus fruits, and potatoes are good sources
of potassium.
48. Tertiary prevention is treatment to prevent long-term
complications. 66. Good sources of magnesium include fish, nuts, and grains.

49. On noticing religious artifacts and literature on a patient’s 67. Beef, oysters, shrimp, scallops, spinach, beets, and greens are
night stand, a culturally aware nurse would ask the patient the good sources of iron.
meaning of the items.
68. The nitrogen balance estimates the difference between the
50. A Mexican patient may request the intervention of a intake and use of protein.
curandero, or faith healer, who involves the family in healing the
patient. 69. A Hindu patient is likely to request a vegetarian diet.

51. In an infant, the normal hemoglobin value is 12 g/dl. 70. No pork or pork products are allowed in a Muslim diet.

52. A patient indicates that he’s coming to terms with having a ADVERTISEMENTS
chronic disease when he says something like: “I’m never going to
get any better,” or when he exhibits hopelessness.
71. In accordance with the “hot-cold” system used by some 91. Alleviating pain by performing a back massage is consistent
Mexicans, Puerto Ricans, and other Hispanic and Latino groups, with the gate control theory.
most foods, beverages, herbs, and drugs are described as “cold.”
92. Pain seems more intense at night because the patient isn’t
72. Milk is high in sodium and low in iron. distracted by daily activities.

73. Discrimination is preferential treatment of individuals of a 93. Older patients commonly don’t report pain because of fear of
particular group. It’s usually discussed in a negative sense. treatment, lifestyle changes, or dependency.

74. Increased gastric motility interferes with the absorption of ***

oral drugs.
94. Utilization review is performed to determine whether the care
75. When feeding an elderly patient, the nurse should limit high- provided to a patient was appropriate and cost-effective.
carbohydrate foods because of the risk of glucose intolerance.
95. A value cohort is a group of people who experienced an out-
76. When feeding an elderly patient, essential foods should be of-the-ordinary event that shaped their values.
given first.
96. A third-party payer is an insurance company.
78. For the patient who abides by Jewish custom, milk and meat
shouldn’t be served at the same meal. 97. Intrathecal injection is administering a drug through the spine.

*** 98. When a patient asks a question or makes a statement that’s

emotionally charged, the nurse should respond to the emotion
Pain Management behind the statement or question rather than to what’s being said
or asked.

99–105. The steps of the trajectory-nursing model are as follows:

79. Only the patient can describe his pain accurately.
Step 1: Identifying the trajectory phase
80. Cutaneous stimulation creates the release of endorphins that
Step 2: Identifying the problems and establishing goals
block the transmission of pain stimuli.

Step 3: Establishing a plan to meet the goals

81. Patient-controlled analgesia (PCA) is a safe method to
relieve acute pain caused by surgical incision, traumatic
Step 4: Identifying factors that facilitate or hinder attainment of
injury, labor and delivery, or cancer.
the goals
82. An Asian-American or European-American typically places
Step 5: Implementing interventions
distance between himself and others when communicating.
Step 6: Evaluating the effectiveness of the interventions
83. Active euthanasia is actively helping a person to die.
106–107. Two goals of Healthy People 2010 are:
84. Brain death is irreversible cessation of all brain function.
Help individuals of all ages to increase the quality of life and the
85. Passive euthanasia is stopping the therapy that’s sustaining
number of years of optimal health
life.
Eliminate health disparities among different segments of the
86. Voluntary euthanasia is actively helping a patient to die at the
population.
patient’s request.
108. A community nurse is serving as a patient’s advocate if she
87. A back rub is an example of the gate-control theory of pain.
tells a malnourished patient to go to a meal program at a local
park.
88. Pain threshold, or pain sensation, is the initial point at which a
patient feels pain.
109. If a patient isn’t following his treatment plan, the nurse
should first ask why.
89. The difference between acute pain and chronic pain is its
duration.
110. When a patient is ill, it’s essential for the members of his
family to maintain communication about his health needs.
90. Referred pain is pain that’s felt at a site other than its origin.
110. Ethnocentrism is the universal belief that one’s way of life is C: Circulation. This category includes everything that affects the
superior to others’. circulation, including fluid and electrolyte disturbances and
disease processes that affect cardiac output.
111. When a nurse is communicating with a patient through an
interpreter, the nurse should speak to the patient and the D: Disease processes. If the patient has no problem with the
interpreter. airway, breathing, or circulation, then the nurse should evaluate
the disease processes, giving priority to the disease process that
112. Prejudice is a hostile attitude toward individuals of a poses the greatest immediate risk. For example, if a patient has
particular group. terminal cancer and hypoglycemia, hypoglycemia is a more
immediate concern.
113. The three phases of the therapeutic relationship are
orientation, working, and termination. E: Everything else. This category includes such issues as writing
any incident report and completing the patient chart. When
114. Patients often exhibit resistive and challenging behaviors in evaluating needs, this category is never the highest priority.
the orientation phase of the therapeutic relationship.
129. Rule utilitarianism is known as the “greatest good for the
115. Abdominal assessment is performed in the following order: greatest number of people” theory.
inspection, auscultation, palpation, and percussion.
130. Egalitarian theory emphasizes that equal access to goods and
116. When measuring blood pressure in a neonate, the nurse services must be provided to the less fortunate by an affluent
should select a cuff that’s no less than one-half and no more than society.
two-thirds the length of the extremity that’s used.
Communication and Patient Education
117. When administering a drug by Z-track, the nurse shouldn’t
use the same needle that was used to draw the drug into the
syringe because doing so could stain the skin.
131. Before teaching any procedure to a patient, the nurse must
118. Sites for intradermal injection include the inner arm, the
assess the patient’s current knowledge and willingness to learn.
upper chest, and on the back, under the scapula.
ADVERTISEMENTS
119. When evaluating whether an answer on an examination is
correct, the nurse should consider whether the action that’s
132. Process recording is a method of evaluating one’s
described promotes autonomy (independence), safety, self-
communication effectiveness.
esteem, and a sense of belonging.
133. Whether the patient can perform a procedure (psychomotor
120. Veracity is truth and is an essential component of a
domain of learning) is a better indicator of the effectiveness of
therapeutic relationship between a health care provider and his
patient teaching than whether the patient can simply state the
patient.
steps involved in the procedure (cognitive domain of learning).

121. Beneficence is the duty to do no harm and the duty to do

134. When communicating with a hearing impaired patient, the
good. There’s an obligation in patient care to do no harm and an
nurse should face him.
equal obligation to assist the patient.
135. When a patient expresses concern about a health-related
122. Nonmaleficence is the duty to do no harm.
issue, before addressing the concern, the nurse should assess the
patient’s level of knowledge.
123–128. Frye’s ABCDE cascade provides a framework for
prioritizing care by identifying the most important treatment
***
concerns.
136. Passive range of motion maintains joint mobility. Resistive
A: Airway. This category includes everything that affects a patent
exercises increase muscle mass.
airway, including a foreign object, fluid from an upper respiratory
infection, and edema from trauma or an allergic reaction. 137. Isometric exercises are performed on an extremity that’s in a
cast.
B: Breathing. This category includes everything that affects the
breathing pattern, including hyperventilation or hypoventilation 138. Anything that’s located below the waist is considered
and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or unsterile; a sterile field becomes unsterile when it comes in
Cheyne-Stokes respiration. contact with any unsterile item; a sterile field must be monitored
continuously; and a border of 1″ (2.5 cm) around a sterile field is
considered unsterile.
139. A “shift to the left” is evident when the number of immature Schedule II drugs, such as morphine, opium, and meperidine
cells (bands) in the blood increases to fight an infection. (Demerol), have a high abuse potential, but currently have
accepted medical uses. Their use may lead to physical or
140. A “shift to the right” is evident when the number of mature psychological dependence.
cells in the blood increases, as seen in advanced liver disease and
pernicious anemia. Schedule III drugs, such as paregoric and butabarbital (Butisol),
have a lower abuse potential than Schedule I or II drugs. Abuse of
141. Before administering preoperative medication, the nurse Schedule III drugs may lead to moderate or low physical or
should ensure that an informed consent form has been signed psychological dependence, or both.
and attached to the patient’s record.
Schedule IV drugs, such as chloral hydrate, have a low abuse
142. A nurse should spend no more than 30 minutes per 8-hour potential compared with Schedule III drugs.
shift providing care to a patient who has a radiation implant.
Schedule V drugs, such as cough syrups that contain codeine,
143. A nurse shouldn’t be assigned to care for more than one have the lowest abuse potential of the controlled substances.
patient who has a radiation implant.
164. During lumbar puncture, the nurse must note the initial
144. Long-handled forceps and a lead-lined container should be intracranial pressure and the color of the cerebrospinal fluid.
available in the room of a patient who has a radiation implant.
165. Cold packs are applied for the first 20 to 48 hours after an
145. Usually, patients who have the same infection and are in injury; then heat is applied. During cold application, the pack is
strict isolation can share a room. applied for 20 minutes and then removed for 10 to 15 minutes to
prevent reflex dilation (rebound phenomenon)
146. Diseases that require strict isolation include and frostbite injury.
chickenpox, diphtheria, and viral hemorrhagic fevers such
as Marburg disease.

147–155. According to Erik Erikson, developmental stages are:

Trust versus mistrust (birth to 18 months)

Autonomy versus shame and doubt (18 months to age 3)

Initiative versus guilt (ages 3 to 5)

Industry versus inferiority (ages 5 to 12)

Identity versus identity diffusion (ages 12 to 18)

Intimacy versus isolation (ages 18 to 25)

Generativity versus stagnation (ages 25 to 60), and

Ego integrity versus despair (older than age 60).

156. An appropriate nursing intervention for the spouse of a

patient who has a serious incapacitating disease is to help him to
mobilize a support system.

157. The most effective way to reduce a fever is to administer an

antipyretic, which lowers the temperature set point.

158–163. The Controlled Substances Act designated five

categories, or schedules, that classify controlled drugs according
to their abuse potential.

Schedule I drugs, such as heroin, have a high abuse potential and

have no currently accepted medical use in the United States.
 Decibel is the unit of measurement of sound.

Informed consent is required for any invasive procedure.

A patient who can’t write his name to give consent for treatment
must make an X in the presence of two witnesses, such as a nurse,
priest, or physician.

The Z-track I.M. injection technique seals the drug deep into the
muscle, thereby minimizing skin irritation and staining. It requires
a needle that’s 1″ (2.5 cm) or longer.

In the event of fire, the acronym most often used is RACE. (R)
Remove the patient. (A) Activate the alarm. (C) Attempt to contain
the fire by closing the door. (E) Extinguish the fire if it can be done
safely.

A registered nurse should assign a licensed vocational nurse or

A blood pressure cuff that’s too narrow can cause a falsely
licensed practical nurse to perform bedside care, such as
elevated blood pressure reading.
suctioning and drug administration.

When preparing a single injection for a patient who takes regular

If a patient can’t void, the first nursing action should be bladder
and neutral protein Hagedorn insulin, the nurse should draw the
palpation to assess for bladder distention.
regular insulin into the syringe first so that it does not
contaminate the regular insulin. The patient who uses a cane should carry it on the unaffected side
and advance it at the same time as the affected extremity.
Rhonchi are the rumbling sounds heard on lung auscultation. They
are more pronounced during expiration than during inspiration. To fit a supine patient for crutches, the nurse should measure
from the axilla to the sole and add 2″ (5 cm) to that
Gavage is forced feeding, usually through a gastric tube (a tube
measurement.
passed into the stomach through the mouth).
Assessment begins with the nurse’s first encounter with the
According to Maslow’s hierarchy of needs, physiologic needs (air,
patient and continues throughout the patient’s stay. The nurse
water, food, shelter, sex, activity, and comfort) have the highest
obtains assessment data through the health history, physical
priority.
examination, and review of diagnostic studies.

The safest and surest way to verify a patient’s identity is to check

The appropriate needle size for insulin injection is 25G and 5/8″
the identification band on his wrist.
long.

In the therapeutic environment, the patient’s safety is the primary

Residual urine is urine that remains in the bladder after voiding.
concern.
The amount of residual urine is normally 50 to 100 ml.

Fluid oscillation in the tubing of a chest drainage system indicates

The five stages of the nursing process are assessment, nursing
that the system is working properly.
diagnosis, planning, implementation, and evaluation.

The nurse should place a patient who has a Sengstaken-

Assessment is the stage of the nursing process in which the nurse
Blakemore tube in semi-Fowler position.
continuously collects data to identify a patient’s actual and
potential health needs.
The nurse can elicit Trousseau’s sign by occluding the brachial or
radial artery. Hand and finger spasms that occur during occlusion
Nursing diagnosis is the stage of the nursing process in which the
indicate Trousseau’s sign and suggest hypocalcemia.
nurse makes a clinical judgment about individual, family, or
community responses to actual or potential health problems or
For blood transfusion in an adult, the appropriate needle size is 16
life processes.
to 20G.

Planning is the stage of the nursing process in which the nurse

Intractable pain is pain that incapacitates a patient and can’t be
assigns priorities to nursing diagnoses, defines short-term and
relieved by drugs.
long-term goals and expected outcomes, and establishes the
nursing care plan.
In an emergency, consent for treatment can be obtained by fax,
telephone, or other telegraphic means.
Implementation is the stage of the nursing process in which the Alcohol is metabolized primarily in the liver. Smaller amounts are
nurse puts the nursing care plan into action, delegates specific metabolized by the kidneys and lungs.
nursing interventions to members of the nursing team, and charts
patient responses to nursing interventions. Petechiae are tiny, round, purplish red spots that appear on the
skin and mucous membranes as a result of intradermal or
Evaluation is the stage of the nursing process in which the nurse submucosal hemorrhage.
compares objective and subjective data with the outcome criteria
and, if needed, modifies the nursing care plan. Purpura is a purple discoloration of the skin that’s caused by
blood extravasation.
Before administering any “as needed” pain medication, the nurse
should ask the patient to indicate the location of the pain. According to the standard precautions recommended by the
Centers for Disease Control and Prevention, the nurse shouldn’t
Jehovah’s Witnesses believe that they shouldn’t receive blood recap needles after use. Most needle sticks result from missed
components donated by other people. needle recapping.

To test visual acuity, the nurse should ask the patient to cover The nurse administers a drug by I.V. push by using a needle and
each eye separately and to read the eye chart with glasses and syringe to deliver the dose directly into a vein, I.V. tubing, or a
without, as appropriate. catheter.

When providing oral care for an unconscious patient, to minimize When changing the ties on a tracheostomy tube, the nurse should
the risk of aspiration, the nurse should position the patient on the leave the old ties in place until the new ones are applied.
side.
A nurse should have assistance when changing the ties on a
During assessment of distance vision, the patient should stand 20′ tracheostomy tube.
(6.1 m) from the chart.
A filter is always used for blood transfusions.
For a geriatric patient or one who is extremely ill, the ideal room
temperature is 66° to 76° F (18.8° to 24.4° C). A four-point (quad) cane is indicated when a patient needs more
stability than a regular cane can provide.
Normal room humidity is 30% to 60%.
A good way to begin a patient interview is to ask, “What made
Hand washing is the single best method of limiting the spread of you seek medical help?”
microorganisms. Once gloves are removed after routine contact
with a patient, hands should be washed for 10 to 15 seconds. When caring for any patient, the nurse should follow standard
precautions for handling blood and body fluids.
To perform catheterization, the nurse should place a woman in
the dorsal recumbent position. Potassium (K+) is the most abundant cation in intracellular fluid.

A positive Homan’s sign may indicate thrombophlebitis. In the four-point, or alternating, gait, the patient first moves the
right crutch followed by the left foot and then the left crutch
Electrolytes in a solution are measured in milliequivalents per liter followed by the right foot.
(mEq/L). A milliequivalent is the number of milligrams per 100
milliliters of a solution. In the three-point gait, the patient moves two crutches and the
affected leg simultaneously and then moves the unaffected leg.
Metabolism occurs in two phases: anabolism (the constructive
phase) and catabolism (the destructive phase). In the two-point gait, the patient moves the right leg and the left
crutch simultaneously and then moves the left leg and the right
The basal metabolic rate is the amount of energy needed to crutch simultaneously.
maintain essential body functions. It’s measured when the patient
is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a The vitamin B complex, the water-soluble vitamins that are
comfortable, warm environment. essential for metabolism, include thiamine (B1), riboflavin (B2),
niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).
The basal metabolic rate is expressed in calories consumed per
hour per kilogram of body weight. When being weighed, an adult patient should be lightly dressed
and shoeless.
Dietary fiber (roughage), which is derived from cellulose, supplies
bulk, maintains intestinal motility, and helps to establish regular Before taking an adult’s temperature orally, the nurse should
bowel habits. ensure that the patient hasn’t smoked or consumed hot or cold
substances in the previous 15 minutes.
The nurse shouldn’t take an adult’s temperature rectally if the A slight difference in blood pressure (5 to 10 mm Hg) between the
patient has a cardiac disorder, anal lesions, or bleeding right and the left arms is normal.
hemorrhoids or has recently undergone rectal surgery.
The nurse should place the blood pressure cuff 1″ (2.5 cm) above
In a patient who has a cardiac disorder, measuring temperature the antecubital fossa.
rectally may stimulate a vagal response and lead to vasodilation
and decreased cardiac output. When instilling ophthalmic ointments, the nurse should waste the
first bead of ointment and then apply the ointment from the inner
When recording pulse amplitude and rhythm, the nurse should canthus to the outer canthus.
use these descriptive measures: +3, bounding pulse (readily
palpable and forceful); +2, normal pulse (easily palpable); +1, The nurse should use a leg cuff to measure blood pressure in an
thready or weak pulse (difficult to detect); and 0, absent pulse obese patient.
(not detectable).
If a blood pressure cuff is applied too loosely, the reading will be
The intraoperative period begins when a patient is transferred to falsely lowered.
the operating room bed and ends when the patient is admitted to
the postanesthesia care unit. Ptosis is drooping of the eyelid.

On the morning of surgery, the nurse should ensure that the A tilt table is useful for a patient with a spinal cord injury,
informed consent form has been signed; that the patient hasn’t orthostatic hypotension, or brain damage because it can move the
taken anything by mouth since midnight, has taken a shower with patient gradually from a horizontal to a vertical (upright) position.
antimicrobial soap, has had mouth care (without swallowing the
water), has removed common jewelry, and has received To perform venipuncture with the least injury to the vessel, the
preoperative medication as prescribed; and that vital signs have nurse should turn the bevel upward when the vessel’s lumen is
been taken and recorded. Artificial limbs and other prostheses are larger than the needle and turn it downward when the lumen is
usually removed. only slightly larger than the needle.

Comfort measures, such as positioning the patient, rubbing the To move a patient to the edge of the bed for transfer, the nurse
patient’s back, and providing a restful environment, may decrease should follow these steps: Move the patient’s head and shoulders
the patient’s need for analgesics or may enhance their toward the edge of the bed. Move the patient’s feet and legs to
effectiveness. the edge of the bed (crescent position). Place both arms well
under the patient’s hips, and straighten the back while moving the
A drug has three names: generic name, which is used in official patient toward the edge of the bed.
publications; trade, or brand, name (such as Tylenol), which is
selected by the drug company; and chemical name, which When being measured for crutches, a patient should wear shoes.
describes the drug’s chemical composition.
The nurse should attach a restraint to the part of the bed frame
To avoid staining the teeth, the patient should take a liquid iron that moves with the head, not to the mattress or side rails.
preparation through a straw.
The mist in a mist tent should never become so dense that it
The nurse should use the Z-track method to administer an I.M. obscures clear visualization of the patient’s respiratory pattern.
injection of iron dextran (Imferon).
To administer heparin subcutaneously, the nurse should follow
An organism may enter the body through the nose, mouth, these steps: Clean, but don’t rub, the site with alcohol. Stretch the
rectum, urinary or reproductive tract, or skin. skin taut or pick up a well-defined skin fold. Hold the shaft of the
needle in a dart position. Insert the needle into the skin at a right
In descending order, the levels of consciousness are alertness, (90-degree) angle. Firmly depress the plunger, but don’t aspirate.
lethargy, stupor, light coma, and deep coma. Leave the needle in place for 10 seconds. Withdraw the needle
gently at the angle of insertion. Apply pressure to the injection
To turn a patient by logrolling, the nurse folds the patient’s arms site with an alcohol pad.
across the chest; extends the patient’s legs and inserts a pillow
between them, if needed; places a draw sheet under the patient; For a sigmoidoscopy, the nurse should place the patient in the
and turns the patient by slowly and gently pulling on the draw knee-chest position or Sims’ position, depending on the
sheet. physician’s preference.

The diaphragm of the stethoscope is used to hear high-pitched Maslow’s hierarchy of needs must be met in the following order:
sounds, such as breath sounds. physiologic (oxygen, food, water, sex, rest, and comfort), safety
and security, love and belonging, self-esteem and recognition, and
self-actualization.
When caring for a patient who has a nasogastric tube, the nurse When leaving an isolation room, the nurse should remove her
should apply a water-soluble lubricant to the nostril to prevent gloves before her mask because fewer pathogens are on the
soreness. mask.

During gastric lavage, a nasogastric tube is inserted, the stomach Skeletal traction, which is applied to a bone with wire pins or
is flushed, and ingested substances are removed through the tongs, is the most effective means of traction.
tube.
The total parenteral nutrition solution should be stored in a
In documenting drainage on a surgical dressing, the nurse should refrigerator and removed 30 to 60 minutes before use. Delivery of
include the size, color, and consistency of the drainage (for a chilled solution can cause pain, hypothermia, venous spasm, and
example, “10 mm of brown mucoid drainage noted on dressing”). venous constriction.

To elicit Babinski’s reflex, the nurse strokes the sole of the Drugs aren’t routinely injected intramuscularly into edematous
patient’s foot with a moderately sharp object, such as a tissue because they may not be absorbed.
thumbnail.
When caring for a comatose patient, the nurse should explain
A positive Babinski’s reflex is shown by dorsiflexion of the great each action to the patient in a normal voice.
toe and fanning out of the other toes.
Dentures should be cleaned in a sink that’s lined with a washcloth.
When assessing a patient for bladder distention, the nurse should
check the contour of the lower abdomen for a rounded mass A patient should void within 8 hours after surgery.
above the symphysis pubis.
An EEG identifies normal and abnormal brain waves.
The best way to prevent pressure ulcers is to reposition the
bedridden patient at least every 2 hours. Samples of feces for ova and parasite tests should be delivered to
the laboratory without delay and without refrigeration.
Antiembolism stockings decompress the superficial blood vessels,
reducing the risk of thrombus formation. The autonomic nervous system regulates the cardiovascular and
respiratory systems.
In adults, the most convenient veins for venipuncture are the
basilic and median cubital veins in the antecubital space. When providing tracheostomy care, the nurse should insert the
catheter gently into the tracheostomy tube. When withdrawing
Two to three hours before beginning a tube feeding, the nurse the catheter, the nurse should apply intermittent suction for no
should aspirate the patient’s stomach contents to verify that more than 15 seconds and use a slight twisting motion.
gastric emptying is adequate.
A low-residue diet includes such foods as roasted chicken, rice,
People with type O blood are considered universal donors. and pasta.

People with type AB blood are considered universal recipients. A rectal tube shouldn’t be inserted for longer than 20 minutes
because it can irritate the rectal mucosa and cause loss of
Hertz (Hz) is the unit of measurement of sound frequency. sphincter control.

Hearing protection is required when the sound intensity exceeds A patient’s bed bath should proceed in this order: face, neck,
84 dB. Double hearing protection is required if it exceeds 104 dB. arms, hands, chest, abdomen, back, legs, perineum.

Prothrombin, a clotting factor, is produced in the liver. To prevent injury when lifting and moving a patient, the nurse
should primarily use the upper leg muscles.
If a patient is menstruating when a urine sample is collected, the
nurse should note this on the laboratory request. Patient preparation for cholecystography includes ingestion of a
contrast medium and a low-fat evening meal.
During lumbar puncture, the nurse must note the initial
intracranial pressure and the color of the cerebrospinal fluid. While an occupied bed is being changed, the patient should be
covered with a bath blanket to promote warmth and prevent
If a patient can’t cough to provide a sputum sample for culture, a exposure.
heated aerosol treatment can be used to help to obtain a sample.
Anticipatory grief is mourning that occurs for an extended time
If eye ointment and eyedrops must be instilled in the same eye, when the patient realizes that death is inevitable.
the eyedrops should be instilled first.
The following foods can alter the color of the feces: beets (red), Quality assurance is a method of determining whether nursing
cocoa (dark red or brown), licorice (black), spinach (green), and actions and practices meet established standards.
meat protein (dark brown).
The five rights of medication administration are the right patient,
When preparing for a skull X-ray, the patient should remove all right drug, right dose, right route of administration, and right
jewelry and dentures. time.

The fight-or-flight response is a sympathetic nervous system The evaluation phase of the nursing process is to determine
response. whether nursing interventions have enabled the patient to meet
the desired goals.
Bronchovesicular breath sounds in peripheral lung fields are
abnormal and suggest pneumonia. Outside of the hospital setting, only the sublingual and
translingual forms of nitroglycerin should be used to relieve acute
Wheezing is an abnormal, high-pitched breath sound that’s anginal attacks.
accentuated on expiration.
The implementation phase of the nursing process involves
Wax or a foreign body in the ear should be flushed out gently by recording the patient’s response to the nursing plan, putting the
irrigation with warm saline solution. nursing plan into action, delegating specific nursing interventions,
and coordinating the patient’s activities.
If a patient complains that his hearing aid is “not working,” the
nurse should check the switch first to see if it’s turned on and The Patient’s Bill of Rights offers patients guidance and protection
then check the batteries. by stating the responsibilities of the hospital and its staff toward
patients and their families during hospitalization.
The nurse should grade hyperactive biceps and triceps reflexes as
+4. To minimize omission and distortion of facts, the nurse should
record information as soon as it’s gathered.
If two eye medications are prescribed for twice-daily instillation,
they should be administered 5 minutes apart. When assessing a patient’s health history, the nurse should record
the current illness chronologically, beginning with the onset of the
In a postoperative patient, forcing fluids helps prevent problem and continuing to the present.
constipation.
When assessing a patient’s health history, the nurse should record
A nurse must provide care in accordance with standards of care the current illness chronologically, beginning with the onset of the
established by the American Nurses Association, state regulations, problem and continuing to the present.
and facility policy.
A nurse shouldn’t give false assurance to a patient.
The kilocalorie (kcal) is a unit of energy measurement that
represents the amount of heat needed to raise the temperature After receiving preoperative medication, a patient isn’t competent
of 1 kilogram of water 1° C. to sign an informed consent form.

As nutrients move through the body, they undergo ingestion, When lifting a patient, a nurse uses the weight of her body
digestion, absorption, transport, cell metabolism, and excretion. instead of the strength in her arms.

The body metabolizes alcohol at a fixed rate, regardless of serum A nurse may clarify a physician’s explanation about an operation
concentration. or a procedure to a patient, but must refer questions about
informed consent to the physician.
In an alcoholic beverage, proof reflects the percentage of alcohol
multiplied by 2. For example, a 100-proof beverage contains 50% When obtaining a health history from an acutely ill or agitated
alcohol. patient, the nurse should limit questions to those that provide
necessary information.
A living will is a witnessed document that states a patient’s desire
for certain types of care and treatment. These decisions are based If a chest drainage system line is broken or interrupted, the nurse
on the patient’s wishes and views on quality of life. should clamp the tube immediately.

The nurse should flush a peripheral heparin lock every 8 hours (if The nurse shouldn’t use her thumb to take a patient’s pulse rate
it wasn’t used during the previous 8 hours) and as needed with because the thumb has a pulse that may be confused with the
normal saline solution to maintain patency. patient’s pulse.

An inspiration and an expiration count as one respiration.

Eupnea is normal respiration. A correctly written patient goal expresses the desired patient
behavior, criteria for measurement, time frame for achievement,
During blood pressure measurement, the patient should rest the and conditions under which the behavior will occur. It’s developed
arm against a surface. Using muscle strength to hold up the arm in collaboration with the patient.
may raise the blood pressure.
Percussion causes five basic notes: tympany (loud intensity, as
Major, unalterable risk factors for coronary artery disease include heard over a gastric air bubble or puffed out cheek),
heredity, sex, race, and age. hyperresonance (very loud, as heard over an emphysematous
lung), resonance (loud, as heard over a normal lung), dullness
Inspection is the most frequently used assessment technique. (medium intensity, as heard over the liver or other solid organ),
and flatness (soft, as heard over the thigh).
Family members of an elderly person in a long-term care facility
should transfer some personal items (such as photographs, a The optic disk is yellowish pink and circular, with a distinct border.
favorite chair, and knickknacks) to the person’s room to provide a
comfortable atmosphere. A primary disability is caused by a pathologic process. A secondary
disability is caused by inactivity.
Pulsus alternans is a regular pulse rhythm with alternating weak
and strong beats. It occurs in ventricular enlargement because the Nurses are commonly held liable for failing to keep an accurate
stroke volume varies with each heartbeat. count of sponges and other devices during surgery.

The upper respiratory tract warms and humidifies inspired air and The best dietary sources of vitamin B6 are liver, kidney, pork,
plays a role in taste, smell, and mastication. soybeans, corn, and whole-grain cereals.

Signs of accessory muscle use include shoulder elevation, Iron-rich foods, such as organ meats, nuts, legumes, dried fruit,
intercostal muscle retraction, and scalene and green leafy vegetables, eggs, and whole grains, commonly have a
sternocleidomastoid muscle use during respiration. low water content.

When patients use axillary crutches, their palms should bear the Collaboration is joint communication and decision making
brunt of the weight. between nurses and physicians. It’s designed to meet patients’
needs by integrating the care regimens of both professions into
Activities of daily living include eating, bathing, dressing, one comprehensive approach.
grooming, toileting, and interacting socially.
Bradycardia is a heart rate of fewer than 60 beats/minute.
Normal gait has two phases: the stance phase, in which the
patient’s foot rests on the ground, and the swing phase, in which A nursing diagnosis is a statement of a patient’s actual or
the patient’s foot moves forward. potential health problem that can be resolved, diminished, or
otherwise changed by nursing interventions.
The phases of mitosis are prophase, metaphase, anaphase, and
telophase. During the assessment phase of the nursing process, the nurse
collects and analyzes three types of data: health history, physical
The nurse should follow standard precautions in the routine care examination, and laboratory and diagnostic test data.
of all patients.
The patient’s health history consists primarily of subjective data,
The nurse should use the bell of the stethoscope to listen for information that’s supplied by the patient.
venous hums and cardiac murmurs.
The physical examination includes objective data obtained by
The nurse can assess a patient’s general knowledge by asking inspection, palpation, percussion, and auscultation.
questions such as “Who is the president of the United States?”
When documenting patient care, the nurse should write legibly,
Cold packs are applied for the first 20 to 48 hours after an injury; use only standard abbreviations, and sign each entry. The nurse
then heat is applied. During cold application, the pack is applied should never destroy or attempt to obliterate documentation or
for 20 minutes and then removed for 10 to 15 minutes to prevent leave vacant lines.
reflex dilation (rebound phenomenon) and frostbite injury.
Factors that affect body temperature include time of day, age,
The pons is located above the medulla and consists of white physical activity, phase of menstrual cycle, and pregnancy.
matter (sensory and motor tracts) and gray matter (reflex
centers). The most accessible and commonly used artery for measuring a
patient’s pulse rate is the radial artery. To take the pulse rate, the
The autonomic nervous system controls the smooth muscles. artery is compressed against the radius.
In a resting adult, the normal pulse rate is 60 to 100 beats/minute. On a drug prescription, the abbreviation p.c. means that the drug
The rate is slightly faster in women than in men and much faster should be administered after meals.
in children than in adults.
After bladder irrigation, the nurse should document the amount,
Laboratory test results are an objective form of assessment data. color, and clarity of the urine and the presence of clots or
sediment.
The measurement systems most commonly used in clinical
practice are the metric system, apothecaries’ system, and After bladder irrigation, the nurse should document the amount,
household system. color, and clarity of the urine and the presence of clots or
sediment.
Before signing an informed consent form, the patient should
know whether other treatment options are available and should Laws regarding patient self-determination vary from state to
understand what will occur during the preoperative, state. Therefore, the nurse must be familiar with the laws of the
intraoperative, and postoperative phases; the risks involved; and state in which she works.
the possible complications. The patient should also have a general
idea of the time required from surgery to recovery. In addition, he Gauge is the inside diameter of a needle: the smaller the gauge,
should have an opportunity to ask questions. the larger the diameter.

A patient must sign a separate informed consent form for each An adult normally has 32 permanent teeth.
procedure.
1. After turning a patient, the nurse should document the position
During percussion, the nurse uses quick, sharp tapping of the used, the time that the patient was turned, and the findings of
fingers or hands against body surfaces to produce sounds. This skin assessment.
procedure is done to determine the size, shape, position, and
density of underlying organs and tissues; elicit tenderness; or 2. PERRLA is an abbreviation for normal pupil assessment findings:
assess reflexes. pupils equal, round, and reactive to light with accommodation.

Ballottement is a form of light palpation involving gentle, 3. When percussing a patient’s chest for postural drainage, the
repetitive bouncing of tissues against the hand and feeling their nurse’s hands should be cupped.
rebound.
4. When measuring a patient’s pulse, the nurse should assess its
A foot cradle keeps bed linen off the patient’s feet to prevent skin rate, rhythm, quality, and strength.
irritation and breakdown, especially in a patient who has
peripheral vascular disease or neuropathy. 5. Before transferring a patient from a bed to a wheelchair, the
nurse should push the wheelchair footrests to the sides and lock
Gastric lavage is flushing of the stomach and removal of ingested its wheels.
substances through a nasogastric tube. It’s used to treat poisoning
or drug overdose. 6. When assessing respirations, the nurse should document their
rate, rhythm, depth, and quality.
During the evaluation step of the nursing process, the nurse
assesses the patient’s response to therapy. 7. For a subcutaneous injection, the nurse should use a 5/8″ to 1″
25G needle.
Bruits commonly indicate life- or limb-threatening vascular
disease. 8. The notation “AA & O × 3” indicates that the patient is awake,
alert, and oriented to person (knows who he is), place (knows
O.U. means each eye. O.D. is the right eye, and O.S. is the left eye. where he is), and time (knows the date and time).

To remove a patient’s artificial eye, the nurse depresses the lower 9. Fluid intake includes all fluids taken by mouth, including foods
lid. that are liquid at room temperature, such as gelatin, custard, and
ice cream; I.V. fluids; and fluids administered in feeding tubes.
The nurse should use a warm saline solution to clean an artificial Fluid output includes urine, vomitus, and drainage (such as from
eye. a nasogastric tube or from a wound) as well
as blood loss, diarrhea or feces, and perspiration.
A thready pulse is very fine and scarcely perceptible.
10. After administering an intradermal injection, the nurse
Axillary temperature is usually 1° F lower than oral temperature. shouldn’t massage the area because massage can irritate the site
and interfere with results.
After suctioning a tracheostomy tube, the nurse must document
the color, amount, consistency, and odor of secretions.
11. When administering an intradermal injection, the nurse 28. A nurse can’t perform duties that violate a rule or regulation
should hold the syringe almost flat against the patient’s skin (at established by a state licensing board, even if they are authorized
about a 15-degree angle), with the bevel up. by a health care facility or physician.

12. To obtain an accurate blood pressure, the nurse should inflate 29. To minimize interruptions during a patient interview, the
the manometer to 20 to 30 mm Hg above the disappearance of nurse should select a private room, preferably one with a door
the radial pulse before releasing the cuff pressure. that can be closed.

13. The nurse should count an irregular pulse for 1 full minute. 30. In categorizing nursing diagnoses, the nurse addresses life-
threatening problems first, followed by potentially life-
14. A patient who is vomiting while lying down should be placed in threatening concerns.
a lateral position to prevent aspiration of vomitus.
31. The major components of a nursing care plan are outcome
15. Prophylaxis is disease prevention. criteria (patient goals) and nursing interventions.

16. Body alignment is achieved when body parts are in proper 32. Standing orders, or protocols, establish guidelines for treating
relation to their natural position. a specific disease or set of symptoms.

17. Trust is the foundation of a nurse-patient relationship. 33. In assessing a patient’s heart, the nurse normally finds the
point of maximal impulse at the fifth intercostal space, near the
18. Blood pressure is the force exerted by the circulating volume apex.
of blood on the arterial walls.
34. The S1 heard on auscultation is caused by closure of the mitral
19. Malpractice is a professional’s wrongful conduct, improper and tricuspid valves.
discharge of duties, or failure to meet standards of care that
causes harm to another. 35. To maintain package sterility, the nurse should open a
wrapper’s top flap away from the body, open each side flap by
20. As a general rule, nurses can’t refuse a patient care touching only the outer part of the wrapper, and open the final
assignment; however, in most states, they may refuse to flap by grasping the turned-down corner and pulling it toward the
participate in abortions. body.

21. A nurse can be found negligent if a patient is injured because 36. The nurse shouldn’t dry a patient’s ear canal or remove wax
the nurse failed to perform a duty that a reasonable and prudent with a cotton-tipped applicator because it may force cerumen
person would perform or because the nurse performed an act against the tympanic membrane.
that a reasonable and prudent person wouldn’t perform.
37. A patient’s identification bracelet should remain in place until
22. States have enacted Good Samaritan laws to encourage the patient has been discharged from the health care facility and
professionals to provide medical assistance at the scene of an has left the premises.
accident without fear of a lawsuit arising from the assistance.
These laws don’t apply to care provided in a health care facility. 38. The Controlled Substances Act designated five categories, or
schedules, that classify controlled drugs according to
23. A physician should sign verbal and telephone orders within the their abuse potential.
time established by facility policy, usually 24 hours. 39. Schedule I drugs, such as heroin, have a high abuse potential
and have no currently accepted medical use in the United States.
24. A competent adult has the right to refuse lifesaving medical
treatment; however, the individual should be fully informed of 40. Schedule II drugs, such as morphine, opium, and meperidine
the consequences of his refusal. (Demerol), have a high abuse potential, but currently have
accepted medical uses. Their use may lead to physical or
25. Although a patient’s health record, or chart, is the health care psychological dependence.
facility’s physical property, its contents belong to the patient.
41. Schedule III drugs, such as paregoric and butabarbital
26. Before a patient’s health record can be released to a third (Butisol), have a lower abuse potential than Schedule I or II drugs.
party, the patient or the patient’s legal guardian must give written Abuse of Schedule III drugs may lead to moderate or low physical
consent. or psychological dependence, or both.

27. Under the Controlled Substances Act, every dose of a 42. Schedule IV drugs, such as chloral hydrate, have a low abuse
controlled drug that’s dispensed by the pharmacy must be potential compared with Schedule III drugs.
accounted for, whether the dose was administered to a patient or
discarded accidentally.
43. Schedule V drugs, such as cough syrups that contain codeine, 62. Before administering a drug, the nurse should identify the
have the lowest abuse potential of the controlled substances. patient by checking the identification band and asking the patient
to state his name.
44. Activities of daily living are actions that the patient must
perform every day to provide self-care and to interact with 63. To clean the skin before an injection, the nurse uses a sterile
society. alcohol swab to wipe from the center of the site outward in a
circular motion.
45. Testing of the six cardinal fields of gaze evaluates the function
of all extraocular muscles and cranial nerves III, IV, and VI. 64. The nurse should inject heparin deep into subcutaneous tissue
at a 90-degree angle (perpendicular to the skin) to prevent skin
46. The six types of heart murmurs are graded from 1 to 6. A irritation.
grade 6 heart murmur can be heard with the stethoscope slightly
raised from the chest. 65. If blood is aspirated into the syringe before an I.M. injection,
the nurse should withdraw the needle, prepare another syringe,
47. The most important goal to include in a care plan is the and repeat the procedure.
patient’s goal.
66. The nurse shouldn’t cut the patient’s hair without written
48. Fruits are high in fiber and low in protein, and should be consent from the patient or an appropriate relative.
omitted from a low-residue diet.
67. If bleeding occurs after an injection, the nurse should apply
49. The nurse should use an objective scale to assess and quantify pressure until the bleeding stops. If bruising occurs, the nurse
pain. Postoperative pain varies greatly among individuals. should monitor the site for an enlarging hematoma.

50. Postmortem care includes cleaning and preparing the 68. When providing hair and scalp care, the nurse should begin
deceased patient for family viewing, arranging transportation to combing at the end of the hair and work toward the head.
the morgue or funeral home, and determining the disposition of
belongings. 69. The frequency of patient hair care depends on the length and
texture of the hair, the duration of hospitalization, and the
51. The nurse should provide honest answers to the patient’s patient’s condition.
questions.
70. Proper function of a hearing aid requires careful handling
52. Milk shouldn’t be included in a clear liquid diet. during insertion and removal, regular cleaning of the ear piece to
prevent wax buildup, and prompt replacement of dead batteries.
53. When caring for an infant, a child, or a confused patient,
consistency in nursing personnel is paramount. 71. The hearing aid that’s marked with a blue dot is for the left
ear; the one with a red dot is for the right ear.
54. The hypothalamus secretes vasopressin and oxytocin, which
are stored in the pituitary gland. 72. A hearing aid shouldn’t be exposed to heat or humidity and
shouldn’t be immersed in water.
55. The three membranes that enclose the brain and spinal
cord are the dura mater, pia mater, and arachnoid. 73. The nurse should instruct the patient to avoid using hair spray
while wearing a hearing aid.
56. A nasogastric tube is used to remove fluid and gas from the
small intestine preoperatively or postoperatively. 74. The five branches of pharmacology are pharmacokinetics,
pharmacodynamics, pharmacotherapeutics, toxicology, and
57. Psychologists, physical therapists, and chiropractors aren’t pharmacognosy.
authorized to write prescriptions for drugs. 75. The nurse should remove heel protectors every 8 hours to
inspect the foot for signs of skin breakdown.
58. The area around a stoma is cleaned with mild soap and water.
76. Heat is applied to promote vasodilation, which reduces pain
59. Vegetables have a high fiber content. caused by inflammation.

ADVERTISEMENTS 77. A sutured surgical incision is an example of healing by first

intention (healing directly, without granulation).
60. The nurse should use a tuberculin syringe to administer a
subcutaneous injection of less than 1 ml. 78. Healing by secondary intention (healing by granulation) is
closure of the wound when granulation tissue fills the defect and
61. For adults, subcutaneous injections require a 25G 5/8″ to 1″
allows reepithelialization to occur, beginning at the wound edges
needle; for infants, children, elderly, or very thin patients, they
and continuing to the center, until the entire wound is covered.
require a 25G to 27G ½” needle.
79. Keloid formation is an abnormality in healing that’s 93. Administering an I.M. injection against the patient’s will and
characterized by overgrowth of scar tissue at the wound site. without legal authority is battery.

80. The nurse should administer procaine penicillin by deep I.M. 94. An example of a third-party payer is an insurance company.
injection in the upper outer portion of the buttocks in the adult or
in the midlateral thigh in the child. The nurse shouldn’t massage 95. The formula for calculating the drops per minute for an I.V.
the injection site. infusion is as follows: (volume to be infused × drip factor) ÷ time
in minutes = drops/minute
81. An ascending colostomy drains fluid feces. A descending
colostomy drains solid fecal matter. 96. On-call medication should be given within 5 minutes of the
call.
82. A folded towel (scrotal bridge) can provide scrotal support for
the patient with scrotal edema caused by vasectomy, 97. Usually, the best method to determine a patient’s cultural or
epididymitis, or orchitis. spiritual needs is to ask him.

83. When giving an injection to a patient who has a bleeding 98. An incident report or unusual occurrence report isn’t part of a
disorder, the nurse should use a small-gauge needle and apply patient’s record, but is an in-house document that’s used for the
pressure to the site for 5 minutes after the injection. purpose of correcting the problem.

84. Platelets are the smallest and most fragile formed element of 99. Critical pathways are a multidisciplinary guideline for patient
the blood and are essential for coagulation. care.

85. To insert a nasogastric tube, the nurse instructs the patient to 100. When prioritizing nursing diagnoses, the following hierarchy
tilt the head back slightly and then inserts the tube. When the should be used: Problems associated with the airway, those
nurse feels the tube curving at the pharynx, the nurse should tell concerning breathing, and those related to circulation.
the patient to tilt the head forward to close the trachea and open
the esophagus by swallowing. (Sips of water can facilitate this 101. The two nursing diagnoses that have the highest priority that
action.) the nurse can assign are Ineffective airway
clearance and Ineffective breathing pattern.
86. Families with loved ones in intensive care units report that
their four most important needs are to have their questions 102. A subjective sign that a sitz bath has been effective is the
answered honestly, to be assured that the best possible care is patient’s expression of decreased pain or discomfort.
being provided, to know the patient’s prognosis, and to feel that
there is hope of recovery. 103. For the nursing diagnosis Deficient diversional activity to be
valid, the patient must state that he’s “bored,” that he has
87. Double-bind communication occurs when the verbal message “nothing to do,” or words to that effect.
contradicts the nonverbal message and the receiver is unsure of
which message to respond to. 104. The most appropriate nursing diagnosis for an individual who
doesn’t speak English is Impaired verbal communication related to
88. A nonjudgmental attitude displayed by a nurse shows that she inability to speak dominant language (English).
neither approves nor disapproves of the patient.
105. The family of a patient who has been diagnosed as hearing
89. Target symptoms are those that the patient finds most impaired should be instructed to face the individual when they
distressing. speak to him.

90. A patient should be advised to take aspirin on an empty 106. Before instilling medication into the ear of a patient who is
stomach, with a full glass of water, and should avoid acidic foods up to age 3, the nurse should pull the pinna down and back to
such as coffee, citrus fruits, and cola. straighten the eustachian tube.

91. For every patient problem, there is a nursing diagnosis; for 107. To prevent injury to the cornea when administering
every nursing diagnosis, there is a goal; and for every goal, there eyedrops, the nurse should waste the first drop and instill the
are interventions designed to make the goal a reality. The keys to drug in the lower conjunctival sac.
answering examination questions correctly are identifying the
problem presented, formulating a goal for the problem, and 108. After administering eye ointment, the nurse should twist the
selecting the intervention from the choices provided that will medication tube to detach the ointment.
enable the patient to reach that goal.
109. When the nurse removes gloves and a mask, she should
92. Fidelity means loyalty and can be shown as a commitment to remove the gloves first. They are soiled and are likely to contain
the profession of nursing and to the patient. pathogens.
110. Crutches should be placed 6″ (15.2 cm) in front of the patient 128. For the patient who abides by Jewish custom, milk and meat
and 6″ to the side to form a tripod arrangement. shouldn’t be served at the same meal.

111. Listening is the most effective communication technique. 129. Whether the patient can perform a procedure (psychomotor
domain of learning) is a better indicator of the effectiveness of
112. Before teaching any procedure to a patient, the nurse must patient teaching than whether the patient can simply state the
assess the patient’s current knowledge and willingness to learn. steps involved in the procedure (cognitive domain of learning).

113. Process recording is a method of evaluating one’s 130. According to Erik Erikson, developmental stages are trust
communication effectiveness. versus mistrust (birth to 18 months), autonomy versus shame and
doubt (18 months to age 3), initiative versus guilt (ages 3 to 5),
114. When feeding an elderly patient, the nurse should limit high- industry versus inferiority (ages 5 to 12), identity versus
carbohydrate foods because of the risk of glucose intolerance. identity diffusion (ages 12 to 18), intimacy versus isolation (ages
18 to 25), generativity versus stagnation (ages 25 to 60), and ego
115. When feeding an elderly patient, essential foods should be integrity versus despair (older than age 60).
given first.
131. When communicating with a hearing impaired patient, the
116. Passive range of motion maintains joint mobility. Resistive nurse should face him.
exercises increase muscle mass.
132. An appropriate nursing intervention for the spouse of a
117. Isometric exercises are performed on an extremity that’s in a patient who has a serious incapacitating disease is to help him to
cast. mobilize a support system.

118. A back rub is an example of the gate-control theory of pain. 133. Hyperpyrexia is extreme elevation in temperature above
106° F (41.1° C).
119. Anything that’s located below the waist is considered
unsterile; a sterile field becomes unsterile when it comes in 134. Milk is high in sodium and low in iron.
contact with any unsterile item; a sterile field must be monitored
continuously; and a border of 1″ (2.5 cm) around a sterile field is 135. When a patient expresses concern about a health-related
considered unsterile. issue, before addressing the concern, the nurse should assess the
patient’s level of knowledge.
120. A “shift to the left” is evident when the number of immature
cells (bands) in the blood increases to fight an infection. 136. The most effective way to reduce a fever is to administer an
antipyretic, which lowers the temperature set point.
ADVERTISEMENTS
137. When a patient is ill, it’s essential for the members of his
121. A “shift to the right” is evident when the number of mature family to maintain communication about his health needs.
cells in the blood increases, as seen in advanced liver disease and
pernicious anemia. 138. Ethnocentrism is the universal belief that one’s way of life is
superior to others.
122. Before administering preoperative medication, the nurse
should ensure that an informed consent form has been signed 139. When a nurse is communicating with a patient through an
and attached to the patient’s record. interpreter, the nurse should speak to the patient and the
interpreter.
123. A nurse should spend no more than 30 minutes per 8-hour
shift providing care to a patient who has a radiation implant. 140. In accordance with the “hot-cold” system used by some
Mexicans, Puerto Ricans, and other Hispanic and Latino groups,
124. A nurse shouldn’t be assigned to care for more than one most foods, beverages, herbs, and drugs are described as “cold.”
patient who has a radiation implant.
141. Prejudice is a hostile attitude toward individuals of a
125. Long-handled forceps and a lead-lined container should be particular group.
available in the room of a patient who has a radiation implant.
142. Discrimination is preferential treatment of individuals of a
126. Usually, patients who have the same infection and are in particular group. It’s usually discussed in a negative sense.
strict isolation can share a room.
143. Increased gastric motility interferes with the absorption of
127. Diseases that require strict isolation include oral drugs.
chickenpox, diphtheria, and viral hemorrhagic fevers such as
Marburg disease.
144. The three phases of the therapeutic relationship are 158. C = Circulation. This category includes everything that affects
orientation, working, and termination. the circulation, including fluid and electrolyte disturbances and
disease processes that affect cardiac output.
145. Patients often exhibit resistive and challenging behaviors in
the orientation phase of the therapeutic relationship. 159. D = Disease processes. If the patient has no problem with the
airway, breathing, or circulation, then the nurse should evaluate
146. Abdominal assessment is performed in the following order: the disease processes, giving priority to the disease process that
inspection, auscultation, percussion & palpation. poses the greatest immediate risk. For example, if a patient has
terminal cancer and hypoglycemia, hypoglycemia is a more
147. When measuring blood pressure in a neonate, the nurse immediate concern.
should select a cuff that’s no less than one-half and no more than
two-thirds the length of the extremity that’s used. 160. E = Everything else. This category includes such issues as
writing an incident report and completing the patient chart. When
148. When administering a drug by Z-track, the nurse shouldn’t evaluating needs, this category is never the highest priority.
use the same needle that was used to draw the drug into the
syringe because doing so could stain the skin. 161. When answering a question on an NCLEX examination, the
basic rule is “assess before action.” The student should evaluate
149. Sites for intradermal injection include the inner arm, the each possible answer carefully. Usually, several answers reflect
upper chest, and on the back, under the scapula. the implementation phase of nursing and one or two reflect the
assessment phase. In this case, the best choice is an assessment
150. When evaluating whether an answer on an examination is response unless a specific course of action is clearly indicated.
correct, the nurse should consider whether the action that’s
described promotes autonomy (independence), safety, self- 162. Rule utilitarianism is known as the “greatest good for the
esteem, and a sense of belonging. greatest number of people” theory.

151. When answering a question on the NCLEX examination, the 163. Egalitarian theory emphasizes that equal access to goods and
student should consider the cue (the stimulus for a thought) and services must be provided to the less fortunate by an affluent
the inference (the thought) to determine whether the inference is society.
correct. When in doubt, the nurse should select an answer that
indicates the need for further information to eliminate ambiguity. 164. Active euthanasia is actively helping a person to die.
For example, the patient complains of chest pain (the stimulus for
the thought) and the nurse infers that the patient is having 165. Brain death is irreversible cessation of all brain function.
cardiac pain (the thought). In this case, the nurse hasn’t
confirmed whether the pain is cardiac. It would be more 166. Passive euthanasia is stopping the therapy that’s sustaining
appropriate to make further assessments. life.

152. Veracity is truth and is an essential component of a 167. A third-party payer is an insurance company.

therapeutic relationship between a health care provider and his
patient. 168. Utilization review is performed to determine whether the
care provided to a patient was appropriate and cost-effective.
153. Beneficence is the duty to do no harm and the duty to do 169. A value cohort is a group of people who experienced an out-
good. There’s an obligation in patient care to do no harm and an of-the-ordinary event that shaped their values.
equal obligation to assist the patient.
170. Voluntary euthanasia is actively helping a patient to die at
154. Nonmaleficence is the duty to do no harm. the patient’s request.

155. Frye’s ABCDE cascade provides a framework for prioritizing 171. Bananas, citrus fruits, and potatoes are good sources
care by identifying the most important treatment concerns. of potassium.

156. A = Airway. This category includes everything that affects a 172. Good sources of magnesium include fish, nuts, and grains.
patent airway, including a foreign object, fluid from an upper
respiratory infection, and edema from trauma or an allergic 173. Beef, oysters, shrimp, scallops, spinach, beets, and greens
reaction. are good sources of iron.

157. B = Breathing. This category includes everything that affects 174. Intrathecal injection is administering a drug through the
the breathing pattern, including hyperventilation or spine.
hypoventilation and abnormal breathing patterns, such as
Korsakoff’s, Biot’s, or Cheyne-Stokes respiration. 175. When a patient asks a question or makes a statement that’s
emotionally charged, the nurse should respond to the emotion
behind the statement or question rather than to what’s being said 201. A patient indicates that he’s coming to terms with having a
or asked. chronic disease when he says, “I’m never going to get any better.”

176. The steps of the trajectory-nursing model are as follows: 202. On noticing religious artifacts and literature on a patient’s
177. Step 1: Identifying the trajectory phase night stand, a culturally aware nurse would ask the patient the
178. Step 2: Identifying the problems and establishing goals meaning of the items.
179. Step 3: Establishing a plan to meet the goals
180. Step 4: Identifying factors that facilitate or hinder attainment 203. A Mexican patient may request the intervention of a
of the goals curandero, or faith healer, who involves the family in healing the
181. Step 5: Implementing interventions patient.
182. Step 6: Evaluating the effectiveness of the interventions
204. In an infant, the normal hemoglobin value is 12 g/dl.
183. A Hindu patient is likely to request a vegetarian diet.
205. The nitrogen balance estimates the difference between the
184. Pain threshold, or pain sensation, is the initial point at which intake and use of protein.
a patient feels pain.
206. Most of the absorption of water occurs in the large intestine.
185. The difference between acute pain and chronic pain is its
duration. 207. Most nutrients are absorbed in the small intestine.

186. Referred pain is pain that’s felt at a site other than its origin. 208. When assessing a patient’s eating habits, the nurse should
ask, “What have you eaten in the last 24 hours?”
187. Alleviating pain by performing a back massage is consistent
with the gate control theory. 209. A vegan diet should include an abundant supply of fiber.

188. Romberg’s test is a test for balance or gait. 210. A hypotonic enema softens the feces, distends the colon, and
stimulates peristalsis.
189. Pain seems more intense at night because the patient isn’t
distracted by daily activities. 211. First-morning urine provides the best sample to measure
glucose, ketone, pH, and specific gravity values.
190. Older patients commonly don’t report pain because of fear
of treatment, lifestyle changes, or dependency. ADVERTISEMENTS

191. No pork or pork products are allowed in a Muslim diet. 212. To induce sleep, the first step is to minimize environmental
stimuli.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase the quality of life and 213. Before moving a patient, the nurse should assess the
the number of years of optimal health patient’s physical abilities and ability to understand instructions as
194. Eliminate health disparities among different segments of the well as the amount of strength required to move the patient.
population.
214. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his
195. A community nurse is serving as a patient’s advocate if she weekly intake by 3,500 calories (approximately 500 calories daily).
tells a malnourished patient to go to a meal program at a local To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly
park. caloric intake by 7,000 calories (approximately 1,000 calories
daily).
196. If a patient isn’t following his treatment plan, the nurse
should first ask why. 215. To avoid shearing force injury, a patient who is completely
immobile is lifted on a sheet.
197. Falls are the leading cause of injury in elderly people.
216. To insert a catheter from the nose through the trachea for
198. Primary prevention is true prevention. Examples are suction, the nurse should ask the patient to swallow.
immunizations, weight control, and smoking cessation.
217. Vitamin C is needed for collagen production.
199. Secondary prevention is early detection. Examples include
purified protein derivative (PPD), breast self-examination, 218. Only the patient can describe his pain accurately.
testicular self-examination, and chest X-ray.
219. Cutaneous stimulation creates the release of endorphins that
200. Tertiary prevention is treatment to prevent long-term block the transmission of pain stimuli.
complications.
220. Patient-controlled analgesia is a safe method to relieve acute 239. Sebaceous glands lubricate the skin.
pain caused by surgical incision, traumatic injury, labor and
delivery, or cancer. 240. To check for petechiae in a dark-skinned patient, the nurse
should assess the oral mucosa.
221. An Asian American or European American typically places
distance between himself and others when communicating. 241. To put on a sterile glove, the nurse should pick up the first
glove at the folded border and adjust the fingers when both
222. The patient who believes in a scientific, or biomedical, gloves are on.
approach to health is likely to expect a drug, treatment,
or surgery to cure illness. 242. To increase patient comfort, the nurse should let the alcohol
dry before giving an intramuscular injection.
223. Chronic illnesses occur in very young as well as middle-aged
and very old people. 243. Treatment for a stage 1 ulcer on the heels includes heel
protectors.
224. The trajectory framework for chronic illness states that
preferences about daily life activities affect treatment decisions. 244. Seventh-Day Adventists are usually vegetarians.

225. Exacerbations of chronic disease usually cause the patient to 245. Endorphins are morphine-like substances that produce a
seek treatment and may lead to hospitalization. feeling of well-being.

226. School health programs provide cost-effective health care for 246. Pain tolerance is the maximum amount and duration of pain
low-income families and those who have no health insurance. that an individual is willing to endure.

227. Collegiality is the promotion of collaboration, development,

and interdependence among members of a profession.

228. A change agent is an individual who recognizes a need for

change or is selected to make a change within an established
entity, such as a hospital.

229. The patients’ bill of rights was introduced by the American

Hospital Association.

230. Abandonment is premature termination of treatment

without the patient’s permission and without appropriate relief of
symptoms.

231. Values clarification is a process that individuals use to

prioritize their personal values.

232. Distributive justice is a principle that promotes equal

treatment for all.

233. Milk and milk products, poultry, grains, and fish are good
sources of phosphate.

234. The best way to prevent falls at night in an oriented, but

restless, elderly patient is to raise the side rails.

235. By the end of the orientation phase, the patient should begin
to trust the nurse.

236. Falls in the elderly are likely to be caused by poor vision.

237. Barriers to communication include language deficits, sensory

deficits, cognitive impairments, structural deficits, and paralysis.

238. The three elements that are necessary for a fire are heat,
oxygen, and combustible material.
 13. According to Erikson, the school-age child
(ages 6 to 12) is in the industry-versus-
inferiority stage of psychosocial
development.
PSYCHIATRIC NURSING
14. When caring for a depressed patient, the
nurse’s first priority is safety because of the
1. According to Kübler-Ross, the five stages of
increased risk of suicide.
death and dying are denial, anger,
bargaining, depression, and acceptance. 15. Echolalia is parrotlike repetition of another
person’s words or phrases.
2. Flight of ideas is an alteration in thought
processes that’s characterized by skipping 16. According to psychoanalytic theory, the ego
from one topic to another, unrelated topic. is the part of the psyche that controls
internal demands and interacts with the
3. La belle indifférence is the lack of concern
outside world at the conscious,
for a profound disability, such as blindness
preconscious, and unconscious levels.
or paralysis that may occur in a patient who
has a conversion disorder. 17. According to psychoanalytic theory, the
superego is the part of the psyche that’s
4. Moderate anxiety decreases a person’s
composed of morals, values, and ethics. It
ability to perceive and concentrate. The
continually evaluates thoughts and actions,
person is selectively inattentive (focuses on
rewarding the good and punishing the bad.
immediate concerns), and the perceptual
(Think of the superego as the “supercop” of
field narrows.
the unconscious.)
5. A patient who has a phobic disorder uses
18. According to psychoanalytic theory, the id is
self-protective avoidance as an ego defense
the part of the psyche that contains
mechanism.
instinctual drives. (Remember i for
6. In a patient who has anorexia nervosa, the instinctual and d for drive.)
highest treatment priority is correction of
19. Denial is the defense mechanism used by a
nutritional and electrolyte imbalances.
patient who denies the reality of an event.
7. A patient who is taking lithium must
20. In a psychiatric setting, seclusion is used to
undergo regular (usually once a month)
reduce overwhelming environmental
monitoring of the blood lithium level
stimulation, protect the patient from self-
because the margin between therapeutic
injury or injury to others, and prevent
and toxic levels is narrow. A normal
damage to hospital property. It’s used for
laboratory value is 0.5 to 1.5 mEq/L.
patients who don’t respond to less
8. Early signs and symptoms of alcohol restrictive interventions. Seclusion controls
withdrawal include anxiety, anorexia, external behavior until the patient can
tremors, and insomnia. They may begin up assume self-control and helps the patient to
to 8 hours after the last alcohol intake. regain self-control.

9. Al-Anon is a support group for families of 21. Tyramine-rich food, such as aged cheese,
alcoholics. chicken liver, avocados, bananas, meat
tenderizer, salami, bologna, Chianti wine,
10. The nurse shouldn’t administer and beer may cause severe hypertension in
chlorpromazine (Thorazine) to a patient a patient who takes a monoamine oxidase
who has ingested alcohol because it may inhibitor.
cause oversedation and respiratory
depression. 22. A patient who takes a monoamine oxidase
inhibitor should be weighed biweekly and
11. Lithium toxicity can occur when sodium and monitored for suicidal tendencies.
fluid intake are insufficient, causing lithium
retention. 23. If the patient who takes a monoamine
oxidase inhibitor has palpitations,
12. An alcoholic who achieves sobriety is called headaches, or severe orthostatic
a recovering alcoholic because no cure for hypotension, the nurse should withhold the
alcoholism exists. drug and notify the physician.
24. Common causes of child abuse are poor 37. According to Erikson, the identity-versus-
impulse control by the parents and the lack role confusion stage occurs between ages
of knowledge of growth and development. 12 and 20.

25. The diagnosis of Alzheimer’s disease is 38. Tolerance is the need for increasing
based on clinical findings of two or more amounts of a substance to achieve an effect
cognitive deficits, progressive worsening of that formerly was achieved with lesser
memory, and the results of a amounts.
neuropsychological test.
39. Suicide is the third leading cause of death
26. Memory disturbance is a classic sign of among white teenagers.
Alzheimer’s disease.
40. Most teenagers who kill themselves made a
27. Thought blocking is loss of the train of previous suicide attempt and left telltale
thought because of a defect in mental signs of their plans.
processing.
41. In Erikson’s stage of generativity versus
28. A compulsion is an irresistible urge to despair, generativity (investment of the self
perform an irrational act, such as walking in in the interest of the larger community) is
a clockwise circle before leaving a room or expressed through procreation, work,
washing the hands repeatedly. community service, and creative endeavors.

29. A patient who has a chosen method and a 42. Alcoholics Anonymous recommends a 12-
plan to commit suicide in the next 48 to 72 step program to achieve sobriety.
hours is at high risk for suicide.
43. Signs and symptoms of anorexia nervosa
30. The therapeutic serum level for lithium is include amenorrhea, excessive weight loss,
0.5 to 1.5 mEq/L. lanugo (fine body hair), abdominal
distention, and electrolyte disturbances.
31. Phobic disorders are treated with
desensitization therapy, which gradually 44. A serum lithium level that exceeds 2.0
exposes a patient to an anxiety-producing mEq/L is considered toxic.
stimulus.
45. Public Law 94-247 (Child Abuse and Neglect
32. Dysfunctional grieving is absent or Act of 1973) requires reporting of suspected
prolonged grief. cases of child abuse to child protection
services.
33. During phase I of the nurse-patient
relationship (beginning, or orientation, 46. The nurse should suspect sexual abuse in a
phase), the nurse obtains an initial history young child who has blood in the feces or
and the nurse and the patient agree to a urine, penile or vaginal discharge, genital
contract. trauma that isn’t readily explained, or a
sexually transmitted disease.
34. During phase II of the nurse-patient
relationship (middle, or working, phase), the 47. An alcoholic uses alcohol to cope with the
patient discusses his problems, behavioral stresses of life.
changes occur, and self-defeating behavior
is resolved or reduced. 48. The human personality operates on three
levels: conscious, preconscious, and
35. During phase III of the nurse-patient unconscious.
relationship (termination, or resolution,
phase), the nurse terminates the 49. Asking a patient an open-ended question is
therapeutic relationship and gives the one of the best ways to elicit or clarify
patient positive feedback on his information.
accomplishments.
50. The diagnosis of autism is often made when
36. According to Freud, a person between ages a child is between ages 2 and 3.
12 and 20 is in the genital stage, during
51. Defense mechanisms protect the
which he learns independence, has an
personality by reducing stress and anxiety.
increased interest in members of the
opposite sex, and establishes an identity. 52. Suppression is voluntary exclusion of
stress-producing thoughts from the
consciousness.
53. In psychodrama, life situations are 66. For electroconvulsive therapy to be
approximated in a structured environment, effective, the patient usually receives 6 to
allowing the participant to recreate and 12 treatments at a rate of 2 to 3 per week.
enact scenes to gain insight and to practice
new skills. 67. During the manic phase of bipolar affective
disorder, nursing care is directed at slowing
54. Psychodrama is a therapeutic technique the patient down because the patient may
that’s used with groups to help participants die as a result of self-induced exhaustion or
gain new perception and self-awareness by injury.
acting out their own or assigned problems.
68. For a patient with Alzheimer’s disease, the
55. A patient who is taking disulfiram nursing care plan should focus on safety
(Antabuse) must avoid ingesting products measures.
that contain alcohol, such as cough syrup,
fruitcake, and sauces and soups made with 69. After sexual assault, the patient’s needs are
cooking wine. the primary concern, followed by
medicolegal considerations.
56. A patient who is admitted to a psychiatric
hospital involuntarily loses the right to sign 70. Patients who are in a maintenance program
out against medical advice. for narcotic abstinence syndrome receive
10 to 40 mg of methadone (Dolophine) in a
57. “People who live in glass houses shouldn’t single daily dose and are monitored to
throw stones” and “A rolling stone gathers ensure that the drug is ingested.
no moss” are examples of proverbs used
during a psychiatric interview to determine 71. Stress management is a short-range goal of
a patient’s ability to think abstractly. psychotherapy.
(Schizophrenic patients think in concrete
72. The mood most often experienced by a
terms and might interpret the glass house
patient with organic brain syndrome is
proverb as “If you throw a stone in a glass
irritability.
house, the house will break.”)
73. Creative intuition is controlled by the right
58. Signs of lithium toxicity include diarrhea,
side of the brain.
tremors, nausea, muscle weakness, ataxia,
and confusion. 74. Methohexital (Brevital) is the general
anesthetic that’s administered to patients
59. A labile affect is characterized by rapid
who are scheduled for electroconvulsive
shifts of emotions and mood.
therapy.
60. Amnesia is loss of memory from an organic
75. The decision to use restraints should be
or inorganic cause.
based on the patient’s safety needs.
61. A person who has borderline personality
76. Diphenhydramine (Benadryl) relieves the
disorder is demanding and judgmental in
extrapyramidal adverse effects of
interpersonal relationships and will attempt
psychotropic drugs.
to split staff by pointing to discrepancies in
the treatment plan. 77. In a patient who is stabilized on lithium
(Eskalith) therapy, blood lithium levels
62. Disulfiram (Antabuse) shouldn’t be taken
should be checked 8 to 12 hours after the
concurrently with metronidazole (Flagyl)
first dose, then two or three times weekly
because they may interact and cause a
during the first month. Levels should be
psychotic reaction.
checked weekly to monthly during
63. In rare cases, electroconvulsive therapy maintenance therapy.
causes arrhythmias and death.
78. The primary purpose of psychotropic drugs
64. A patient who is scheduled for is to decrease the patient’s symptoms,
electroconvulsive therapy should receive which improves function and increases
nothing by mouth after midnight to prevent compliance with therapy.
aspiration while under anesthesia.
79. Manipulation is a maladaptive method of
65. Electroconvulsive therapy is normally used meeting one’s needs because it disregards
for patients who have severe depression the needs and feelings of others.
that doesn’t respond to drug therapy.
80. If a patient has symptoms of lithium that the purpose of the therapy is to
toxicity, the nurse should withhold one produce a positive change.
dose and call the physician.
97. A basic assumption of psychoanalytic
81. A patient who is taking lithium (Eskalith) for theory is that all behavior has meaning.
bipolar affective disorder must maintain a
balanced diet with adequate salt intake. 98. Catharsis is the expression of deep feelings
and emotions.
82. A patient who constantly seeks approval or
assistance from staff members and other 99. According to the pleasure principle, the
patients is demonstrating dependent psyche seeks pleasure and avoids
behavior. unpleasant experiences, regardless of the
consequences.
83. Alcoholics Anonymous advocates total
abstinence from alcohol. 100. A patient who has a conversion disorder
resolves a psychological conflict through
84. Methylphenidate (Ritalin) is the drug of the loss of a specific physical function (for
choice for treating attention deficit example, paralysis, blindness, or inability to
hyperactivity disorder in children. swallow). This loss of function is
involuntary, but diagnostic tests show no
85. Setting limits is the most effective way to organic cause.
control manipulative behavior.
101. Chlordiazepoxide (Librium) is the drug of
86. Violent outbursts are common in a patient choice for treating alcohol withdrawal
who has borderline personality disorder. symptoms.
87. When working with a depressed patient, the 102. For a patient who is at risk for alcohol
nurse should explore meaningful losses. withdrawal, the nurse should assess the
pulse rate and blood pressure every 2
88. An illusion is a misinterpretation of an
hours for the first 12 hours, every 4 hours
actual environmental stimulus.
for the next 24 hours, and every 6 hours
89. Anxiety is nonspecific; fear is specific. thereafter (unless the patient’s condition
becomes unstable).
90. Extrapyramidal adverse effects are
common in patients who take antipsychotic 103. Alcohol detoxification is most successful
drugs. when carried out in a structured
environment by a supportive,
91. The nurse should encourage an angry nonjudgmental staff.
patient to follow a physical exercise
program as one of the ways to ventilate 104. The nurse should follow these guidelines
feelings. when caring for a patient who is
experiencing alcohol withdrawal: Maintain a
92. Depression is clinically significant if it’s calm environment, keep intrusions to a
characterized by exaggerated feelings of minimum, speak slowly and calmly, adjust
sadness, melancholy, dejection, lighting to prevent shadows and glare, call
worthlessness, and hopelessness that are the patient by name, and have a friend or
inappropriate or out of proportion to family member stay with the patient, if
reality. possible.
93. Free-floating anxiety is anxiousness with 105. The therapeutic regimen for an alcoholic
generalized apprehension and pessimism patient includes folic acid, thiamine, and
for unknown reasons. multivitamin supplements as well as
adequate food and fluids.
94. In a patient who is experiencing intense
anxiety, the fight-or-flight reaction (alarm 106. A patient who is addicted to opiates (drugs
reflex) may take over. derived from poppy seeds, such as heroin
and morphine) typically experiences
95. Confabulation is the use of imaginary
withdrawal symptoms within 12 hours after
experiences or made-up information to fill
the last dose. The most severe symptoms
missing gaps of memory.
occur within 48 hours and decrease over
96. When starting a therapeutic relationship the next 2 weeks.
with a patient, the nurse should explain
107. Reactive depression is a response to a 121. Idea of reference is an incorrect belief that
specific life event. the statements or actions of others are
related to oneself.
108. Projection is the unconscious assigning of a
thought, feeling, or action to someone or 122. Group therapy provides an opportunity for
something else. each group member to examine
interactions, learn and practice successful
109. Sublimation is the channeling of interpersonal communication skills, and
unacceptable impulses into socially explore emotional conflicts.
acceptable behavior.
123. Korsakoff’s syndrome is believed to be a
110. Repression is an unconscious defense chronic form of Wernicke’s encephalopathy.
mechanism whereby unacceptable or It’s marked by hallucinations, confabulation,
painful thoughts, impulses, memories, or amnesia, and disturbances of orientation.
feelings are pushed from the consciousness
or forgotten. 124. A patient with antisocial personality
disorder often engages in confrontations
111. Hypochondriasis is morbid anxiety about with authority figures, such as police,
one’s health associated with various parents, and school officials.
symptoms that aren’t caused by organic
disease. 125. A patient with paranoid personality
disorder exhibits suspicion, hypervigilance,
112. Denial is a refusal to acknowledge feelings, and hostility toward others.
thoughts, desires, impulses, or external
facts that are consciously intolerable. 126. Depression is the most common psychiatric
disorder.
113. Reaction formation is the avoidance of
anxiety through behavior and attitudes that 127. Adverse reactions to tricyclic antidepressant
are the opposite of repressed impulses and drugs include tachycardia, orthostatic
drives. hypotension, hypomania, lowered seizure
threshold, tremors, weight gain, problems
114. Displacement is the transfer of with erections or orgasms, and anxiety.
unacceptable feelings to a more acceptable
object. 128. The Minnesota Multiphasic Personality
Inventory consists of 550 statements for the
115. Regression is a retreat to an earlier subject to interpret. It assesses personality
developmental stage. and detects disorders, such as depression
and schizophrenia, in adolescents and
116. According to Erikson, an older adult (age 65
adults.
or older) is in the developmental stage of
integrity versus despair. 129. Organic brain syndrome is the most
common form of mental illness in elderly
117. Family therapy focuses on the family as a
patients.
whole rather than the individual. Its major
objective is to reestablish rational 130. A person who has an IQ of less than 20 is
communication between family members. profoundly retarded and is considered a
total-care patient.
118. When caring for a patient who is hostile or
angry, the nurse should attempt to remain 131. Reframing is a therapeutic technique that’s
calm, listen impartially, use short sentences, used to help depressed patients to view a
and speak in a firm, quiet voice. situation in alternative ways.
119. Ritualism and negativism are typical toddler 132. Fluoxetine (Prozac), sertraline (Zoloft), and
behaviors. They occur during the paroxetine (Paxil) are serotonin reuptake
developmental stage identified by Erikson inhibitors used to treat depression.
as autonomy versus shame and doubt.
133. The early stage of Alzheimer’s disease lasts
120. Circumstantiality is a disturbance in 2 to 4 years. Patients have inappropriate
associated thought and speech patterns in affect, transient paranoia, disorientation to
which a patient gives unnecessary, minute time, memory loss, careless dressing, and
details and digresses into inappropriate impaired judgment.
thoughts that delay communication of
central ideas and goal achievement.
134. The middle stage of Alzheimer’s disease cover memory lapses or periods of
lasts 4 to 7 years and is marked by amnesia.
profound personality changes, loss of
independence, disorientation, confusion, 147. People with obsessive-compulsive disorder
inability to recognize family members, and realize that their behavior is unreasonable,
nocturnal restlessness. but are powerless to control it.

135. The last stage of Alzheimer’s disease occurs 148. When witnessing psychiatric patients who
during the final year of life and is are engaged in a threatening confrontation,
characterized by a blank facial expression, the nurse should first separate the two
seizures, loss of appetite, emaciation, individuals.
irritability, and total dependence.
149. Patients with anorexia nervosa or bulimia
136. Threatening a patient with an injection for must be observed during meals and for
failing to take an oral drug is an example of some time afterward to ensure that they
assault. don’t purge what they have eaten.

137. Reexamination of life goals is a major 150. Transsexuals believe that they were born
developmental task during middle the wrong gender and may seek hormonal
adulthood. or surgical treatment to change their
gender.
138. Acute alcohol withdrawal causes anorexia,
insomnia, headache, and restlessness and 151. Fugue is a dissociative state in which a
escalates to a syndrome that’s person leaves his familiar surroundings,
characterized by agitation, disorientation, assumes a new identity, and has amnesia
vivid hallucinations, and tremors of the about his previous identity. (It’s also
hands, feet, legs, and tongue. described as “flight from himself.”)

139. In a hospitalized alcoholic, alcohol 152. In a psychiatric setting, the patient should
withdrawal delirium most commonly occurs be able to predict the nurse’s behavior and
3 to 4 days after admission. expect consistent positive attitudes and
approaches.
140. Confrontation is a communication
technique in which the nurse points out 153. When establishing a schedule for a one-to-
discrepancies between the patient’s words one interaction with a patient, the nurse
and his nonverbal behaviors. should state how long the conversation will
last and then adhere to the time limit.
141. For a patient with substance-induced
delirium, the time of drug ingestion can 154. Thought broadcasting is a type of delusion
help to determine whether the drug can be in which the person believes that his
evacuated from the body. thoughts are being broadcast for the world
to hear.
142. Treatment for alcohol withdrawal may
include administration of I.V. glucose for 155. Lithium should be taken with food. A
hypoglycemia, I.V. fluid containing thiamine patient who is taking lithium shouldn’t
and other B vitamins, and antianxiety, restrict his sodium intake.
antidiarrheal, anticonvulsant, and
156. A patient who is taking lithium should stop
antiemetic drugs.
taking the drug and call his physician if he
143. The alcoholic patient receives thiamine to experiences vomiting, drowsiness, or
help prevent peripheral neuropathy and muscle weakness.
Korsakoff’s syndrome.
157. The patient who is taking a monoamine
144. Alcohol withdrawal may precipitate seizure oxidase inhibitor for depression can include
activity because alcohol lowers the seizure cottage cheese, cream cheese, yogurt, and
threshold in some people. sour cream in his diet.

145. Paraphrasing is an active listening 158. Sensory overload is a state in which sensory
technique in which the nurse restates what stimulation exceeds the individual’s
the patient has just said. capacity to tolerate or process it.

146. A patient with Korsakoff’s syndrome may

use confabulation (made up information) to
159. Symptoms of sensory overload include a 175. Flight of ideas is movement from one topic
feeling of distress and hyperarousal with to another without any discernible
impaired thinking and concentration. connection.

160. In sensory deprivation, overall sensory 176. Conduct disorder is manifested by extreme
input is decreased. behavior, such as hurting people and
animals.
161. A sign of sensory deprivation is a decrease
in stimulation from the environment or 177. During the “tension-building” phase of an
from within oneself, such as daydreaming, abusive relationship, the abused individual
inactivity, sleeping excessively, and feels helpless.
reminiscing.
178. In the emergency treatment of an alcohol-
162. The three stages of general adaptation intoxicated patient, determining the blood-
syndrome are alarm, resistance, and alcohol level is paramount in determining
exhaustion. the amount of medication that the patient
needs.
163. A maladaptive response to stress is drinking
alcohol or smoking excessively. 179. Side effects of the antidepressant
fluoxetine (Prozac) include diarrhea,
164. Hyperalertness and the startle reflex are decreased libido, weight loss, and dry
characteristics of posttraumatic stress mouth.
disorder.
180. Before electroconvulsive therapy, the
165. A treatment for a phobia is desensitization, patient is given the skeletal muscle relaxant
a process in which the patient is slowly succinylcholine (Anectine) by I.V.
exposed to the feared stimuli. administration.
166. Symptoms of major depressive disorder 181. When a psychotic patient is admitted to an
include depressed mood, inability to inpatient facility, the primary concern is
experience pleasure, sleep disturbance, safety, followed by the establishment of
appetite changes, decreased libido, and trust.
feelings of worthlessness.
182. An effective way to decrease the risk of
167. Clinical signs of lithium toxicity are nausea, suicide is to make a suicide contract with
vomiting, and lethargy. the patient for a specified period of time.
168. Asking too many “why” questions yields 183. A depressed patient should be given
scant information and may overwhelm a sufficient portions of his favorite foods, but
psychiatric patient and lead to stress and shouldn’t be overwhelmed with too much
withdrawal. food.
169. Remote memory may be impaired in the 184. The nurse should assess the depressed
late stages of dementia. patient for suicidal ideation.
170. According to the DSM-IV, bipolar II disorder 185. Delusional thought patterns commonly
is characterized by at least one manic occur during the manic phase of bipolar
episode that’s accompanied by hypomania. disorder.
171. The nurse can use silence and active 186. Apathy is typically observed in patients who
listening to promote interactions with a have schizophrenia.
depressed patient.
187. Manipulative behavior is characteristic of a
172. A psychiatric patient with a substance patient who has passive– aggressive
abuse problem and a major psychiatric personality disorder.
disorder has a dual diagnosis.
188. When a patient who has schizophrenia
173. When a patient is readmitted to a mental begins to hallucinate, the nurse should
health unit, the nurse should assess redirect the patient to activities that are
compliance with medication orders. focused on the here and now.
174. Alcohol potentiates the effects of tricyclic 189. When a patient who is receiving an
antidepressants. antipsychotic drug exhibits muscle rigidity
 and tremors, the nurse should administer 205. Trihexyphenidyl (Artane) and benztropine
an antiparkinsonian drug (for example, (Cogentin) are administered to counteract
Cogentin or Artane) as ordered. extrapyramidal adverse effects.

190. A patient who is receiving lithium (Eskalith) 206. To prevent hypertensive crisis, a patient
therapy should report diarrhea, vomiting, who is taking a monoamine oxidase
drowsiness, muscular weakness, or lack of inhibitor should avoid consuming aged
coordination to the physician immediately. cheese, caffeine, beer, yeast, chocolate,
liver, processed foods, and monosodium
191. The therapeutic serum level of lithium glutamate.
(Eskalith) for maintenance is 0.6 to 1.2
mEq/L. 207. Extrapyramidal symptoms include
parkinsonism, dystonia, akathisia (“ants in
192. Obsessive-compulsive disorder is an the pants”), and tardive dyskinesia.
anxiety-related disorder.
208. One theory that supports the use of
193. Al-Anon is a self-help group for families of electroconvulsive therapy suggests that it
alcoholics. “resets” the brain circuits to allow normal
function.
194. Desensitization is a treatment for phobia, or
irrational fear. 209. A patient who has obsessive-compulsive
disorder usually recognizes the
195. After electroconvulsive therapy, the patient
senselessness of his behavior but is
is placed in the lateral position, with the
powerless to stop it (ego-dystonia).
head turned to one side.
210. In helping a patient who has been abused,
196. A delusion is a fixed false belief.
physical safety is the nurse’s first priority.
197. Giving away personal possessions is a sign
211. Pemoline (Cylert) is used to treat attention
of suicidal ideation. Other signs include
deficit hyperactivity disorder (ADHD).
writing a suicide note or talking about
suicide. 212. Clozapine (Clozaril) is contraindicated in
pregnant women and in patients who have
198. Agoraphobia is fear of open spaces.
severe granulocytopenia or severe central
199. A person who has paranoid personality nervous system depression.
disorder projects hostilities onto others.
213. Repression, an unconscious process, is the
200. To assess a patient’s judgment, the nurse inability to recall painful or unpleasant
should ask the patient what he would do if thoughts or feelings.
he found a stamped, addressed envelope.
214. Projection is shifting of unwanted
An appropriate response is that he would
characteristics or shortcomings to others
mail the envelope.
(scapegoat).
201. After electroconvulsive therapy, the patient
215. Hypnosis is used to treat psychogenic
should be monitored for post-shock
amnesia.
amnesia.
216. Disulfiram (Antabuse) is administered orally
202. A mother who continues to perform
as an aversion therapy to treat alcoholism.
cardiopulmonary resuscitation after a
physician pronounces a child dead is 217. Ingestion of alcohol by a patient who is
showing denial. taking disulfiram (Antabuse) can cause
severe reactions, including nausea and
203. Transvestism is a desire to wear clothes
vomiting, and may endanger the patient’s
usually worn by members of the opposite
life.
sex.
218. Improved concentration is a sign that
204. Tardive dyskinesia causes excessive
lithium is taking effect.
blinking and unusual movement of the
tongue, and involuntary sucking and 219. Behavior modification, including time-outs,
chewing. token economy, or a reward system, is a
treatment for attention deficit hyperactivity
disorder.
 220. For a patient who has anorexia nervosa, the E- ends with pril- captopril (capoten) enalapril (vasotec)
nurse should provide support at mealtime R- rise slowly to reduce orthostatic hypotension
T- treatment of htn
and record the amount the patient eats.
E- evaluate BP
6.      Beta- adrenergic blockers
221. A significant toxic risk associated with
end in lol- atenolol (Tenormin)
clozapine (Clozaril) administration is blood B- bradycardia
dyscrasia. B- blood pressure too low
B- bronchial constriction
222. Adverse effects of haloperidol (Haldol) B- blood sugar is masked when low
administration include drowsiness; 7.      Calcium channel blocker
insomnia; weakness; headache; and amlodipine (norvasc), diltiazem (cardizem), nifedipine (procardia)
extrapyramidal symptoms, such as B- blocks calcium access to cells
I- indicated for htn
akathisia, tardive dyskinesia, and dystonia. L- let client take drug with milk or meal
L- light and moisture- protect
223. Hypervigilance and déjà vu are signs of 8.      Diuretics
posttraumatic stress disorder (PTSD). D- diet; increase K+ for all except aldactone
I- intake, output, daily weight monitoring
224. A child who shows dissociation has U- undesirable effects- F&E imbalance
probably been abused. R- review HR, BP, and electrolytes
E- elderly careful, evening dose not recommended
225. Confabulation is the use of fantasy to fill in T- take with or after meals and in AM
gaps of memory. I- incrase risk of orthostatic hypotension, move slowly
C- cancel alcohol and cigs

1.      Digoxin (Lanoxin)
D- dig level 2ng/ml or greater is toxic
I- inhibits sodium potassium ATPase
G-GI or CNS signs indicate adverse effects (N/A for adult toxicity,
stomach upset in older child
O-output, intake, and weight should be monitored
X- dont give if pulse is less than 60 bpm
I- indicated for CHF- a-fib
N- note K+, ECG, and renal function tests
2.      Epinephrine
N- nervousness (undesirable effect)
A- angina, arrhythmia (undesirable)
S- sugar is increased
C- cardiac arrest
A- allergic reaction
R-respiratory bronchodilator

3.      Norepinephrine (levophed)
S- stim alpha and beta adrenergic receptors
H- hypovolemia- should be corrected before using drug
O- output of urine should increase
C- constriction of blood vessels
K- keep monitoring vital signs every 5-15 min
4.      Nitroglycerin
A- avoid alcohol
N- note BP and apical pulse before admin
G- given to relax the vascular smooth system
I- indicated for angina pectoris
N-note for postural hypotension; rise slowly
A- advice client to see medical assistance if pain is unrelieved after
3 doses with 5 min interval
5.      ACE inhibitors
S- suppresses renin angiotensin aldosterone system
W- warn clinet with renal or thyroid diseases