PSYCHIATRIC NURSING REVIEW NOTES I

Psychiatric nursing review notes an interpersonal process whereby the professional nurse practitioner, through the therapeutic use of self art and nursing theories (science), assists clients to achieve psychosocial well being.

Mental health balance in a person’s internal life and adaptation to reality mental ill-health state of imbalance characterized by a disturbance in a person’s thoughts, feelings, and behavior, poverty, and abuses are major risk factors.

PSYCHIATRIC NURSING REVIEW NOTES

Mental hygiene measures to promote mental health prevent mental illness and suffering and facilitate rehabilitation and if necessary find meaning in these experiences. The main tool for the therapeutic use of self. It requires self-awareness.

Methods to increase self-awareness
Introspection, Discussion, Experience, Roleplay

Neurosis any long term mental or behavioral d/o in which contact with reality has retained the condition is recognized by the patient as abnormal. Essentially features anxiety or behavior exaggerated designed to avoid anxiety ( anxiety d/o; hysteria to conversion d/o, amnesia, fugue, multiple personalities, and depersonalization- dissociative. Result of an inappropriate early program in psychoanalysis little value.

Benefits from Behavior Therapy


Psychosis mental or behavioral disorder wherein the patient loses contact with reality. Presence of delusions, hallucinations, severe thought disturbances, alteration of mood, poverty of thought, and abnormal behavior (schizophrenia, the major disorder of effect ( manic – depression), major paranoid states, and organic mental disorder. Benefits from psychoanalysis and antipsychotics.

Common Behavioral Signs and Symptoms

Disturbances in perception
Illusion misinterpretation of an actual external stimuli
Hallucinations false sensory perception in the absence of external stimuli
Disturbances in thinking and speech
neologism coining of words that people do not understand
Circumstantiality over the inclusion of inappropriate thoughts and details
Word salad an incoherent mixture of words and phrases with no logical sequence
Verbigeration meaningless repetition of words and phrases
Perseveration the persistence of a response to a previous question
Echolalia pathological repetition of words of others
Aphasia speech difficulty and disturbance
Expressive, receptive or global
Flight of ideas shifting of one topic from one subject to another
Looseness of association incoherent, the illogical flow of thoughts(unrelated way)
Clang association the sound of the word gives direction to the flow of thought
Delusion persistent false belief, rigidly held
Delusions of grandeur special /important in a way
Persecutory threatened
Ideas of reference-situation/events.
Somatic body reacting in a particular way
Magical thinking primitive thought process thoughts alone can change events
Autistic thinking regressive thought process-subjective interpretations not validated with objective reality

Disturbances of effect
Inappropriate disharmony between the stimuli and the emotional reaction
Blunted affect the severe reduction in emotional reaction
Flat affect absence or near absence of emotional reaction
Apathy dulled emotional tone
Depersonalization the feeling of strangeness from one’s self
Derealization the feeling of strangeness towards the environment
Agnosia lack of sensory stimuli integration

Disturbances in motor activity
Echopraxia imitation of the posture of others
Waxy flexibility maintaining position for a long period of time
Ataxia Loss of balance
Akathesia extreme restlessness
Dystonia uncoordinated spastic movements of the body
Tardive dyskinesia involuntary twitching or muscle movements
Apraxia involuntary unpurposeful movements

Disturbances in memory
Confabulation filling of memory gaps
Déjà vu – 2 time-like feeling
nd

Jamais vu not having been to the place one has been before
Amnesia memory loss (inability to recall past events)
Retrograde distant past
Anterograde immediate past
Anomia lack of memory of items

Dynamics of Human Behavior

Personality integration of systems and habits representing individuals characteristic adjustment to his environment expressed through behavior. Individualistic, unique, predictable(stability and consistency).Determinants are psychological, cultural, biological ( not inherited), and familial. Analysis of potential support systems or stressors, potential risk factors.

The satisfaction of human needs!

  1. Physiological(oxygen , fluids, nutrition, temp.,elimination,shelter,rest,sex)
  2. Safety and security(physical and psychological)
  3. Love and belongingness
  4. Self-esteem
  5. Self –actualization

Three divisions of the mind

A conscious focus on awareness

Subconscious recalled at will

Unconscious never recalled / largest part
Learning change in behavior through – insight, relearning and remotivation

Practice Question Related to Fundamental Nursing, Medical Surgical Nursing, Pscyhiatric Nursing and Communicable Disease.

Communicable Disease Nursing Question and Rationale Part 1

This communicable disease nursing is related to airborne precautions, meningococcal meningitis, radioactive iodine, tuberculosis, and head lice.

communicable diseases
Communicable Disease Nursing

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that

a. Visitors must wear a mask and a gown
b. There are no special requirements for visitors of clients on contact
c. Visitors should wash their hands before and after touching the client
d. Visitors should wear gloves if they touch the client

Rationale:

C is the correct answer.The visitors should wash their hands before and after touching the client Gown and gloves are worn by persons coming in contact with the wounds or infected equipment.

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition?

a. Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
b. A positive purified protein derivative with an abnormal chest x-ray
c. A tentative diagnosis of viral pneumonia with productive brown sputum.
d. Advanced carcinoma of the lung with hemoptysis

Rationale:

B is the correct answer.A positive purified protein derivative with an abnormal chest x-ray. The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. When signs and symptoms do occur, they”re often similar to those of mononucleosis, including: sore throat, fever, muscle aches, fatigue. Good handwashing is recommended for CMV.

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

a. Institute seizure precautions
b. Monitor neurologic status every hour
c. Place in respiratory/secretion precautions
d. Cefataxime IV 50 mg/kg/day divided q6h

Rationale:

C is the correct answer. Meningococcal meningitis has the risk of being a bacterial infection. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitor neurological status along with vital signs, institute seizure precautions and lastly maintenance of optimum hydration. The first action is for nurses to take any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation.

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

a. Reverse
b. Airbourne
c. Standard precautions
d. Contact

Rationale:

D is the correct answer. Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient”s sputum is expected. A private room and contact precautions , along with good hand washing techniques, are the best defenses against the spread of MRSA pneumonia.

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

a. An infant with a positive culture of stool of Shigella
b. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
c. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
d. A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

Rationale:

B is the correct answer. Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options a and d may need contact isolation precautions. Option c findings may indicate the initial stage of the autoimmune deficency syndrome (AIDS).

Pratice Question Test

A client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements?

a. In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice
b. Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice
c. Your family can use the same bathroom that you use without any special preacautions
d. Drink plenty of water and empty your bladder often during the initial 3 days of therapy

Rationale:

A is the correct answer. The client”s urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters a day for the initial 48 hours to help remove the agent from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person.

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, to be implemented in which of these?

a. Apply appropriate signs outside and inside the room
b. Apply a mask with a shield if there is a risk of fluid splash
c. Wear a gown to change soiled linens form incontinence
d. Have gloves on while handling bedpans with feces

Rationale:

D is the correct answer. The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material. All of the other actions are correct but not the most significant.

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?

a. Have the client cough into a tissue and dispose in a separate bag
b. Instruct the client to cover the mouth with a tissue when coughing
c. Reinforce for all to wash their hands before and after entering the room
d. Place client in a negative pressure private room and have all whoenter the room use masks with shields

Rationale:

D is correct. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries (Africa, Asia, South America), the transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled.

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

a. The treatment requires reapplication in 8 to 10 days
b. Bedding and clothing can be boiled or steamed
c. Children are not to share hats, scarves, and combs
d. Nit combs are necessary to comb out nits.

Rationale:

C is the correct answer. Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats, and other items of clothing that touch the hair. All of the options are correct statements. However they do not best answer the question of how to prevent the spread of lice in a school setting.

During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?

a. Wash hands thoroughly before and after client contact
b. Wear gloves when in contact with body secretions
c. Double glove when in contact with feces or vomitus
d. Wear gloves when disposing of contaminated linens

Rationale:

A is correct. Gram-negative bacilli cause Salmonella infection. Two million new cases appear each year. Lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are correct actions. The primary action is to wash the hands.

Practice Question Related to Fundamental Of Nursing

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Practice Question Related to Psychiatric Nursing

Psychiatric Nursing Practice Quiz Part II

This psychiatric nursing is related to toxicity, stress syndrome, nursing assistant and grief.

Psychiatric Nursing

Bong is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication?

a. Librium
b. Valium
c. Ativan
d. Haldol

Rationale:

D is the correct answer. The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.

Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?

a. Shake
b. Tea
c. Cranberry Juice
d. Grape juice

Rationale:

C is the correct answer. An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 and accelerate excretion.

When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?

a. Facilitating progressive review of the accident and its consequences
b. Postponing discussion of the accident until the client brings it up
c. Telling the client to avoid details of the accident
d. Helping the client to evaluate her sister’s behavior

Rationale:

A is the correct answer.The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?

a. Tell the client he’ll need to wait until supper to eat if he misses lunch
b. Invite the client to lunch and accompany him to the dining room
c. Inform the client that he has 10 minutes to get to the dining room for lunch
d. Take the client a lunch tray and let the client eat in his room

Rationale:

B is the correct answer . The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.

The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:

a. Presenting full reality of the loss of the individuals
b. Directing the individual’s activities at this time
c. Staying with the individuals involved
d. Mobilizing the individual’s support system

Rationale:

C is the correct answer. This provides support until the individuals coping mechanisms and personal support systems can be immobilized.

Practice Question Test

Practice Question Related to Fundamental of Nursing

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Practice Question Related to Psychiatric Nursing

Psychiatric Nursing Practice Quiz Part I

This psychiatric nursing practice quiz is related to neuromuscular, dementia, mental health, anorexia, agitation and narcissistic personality.

Psychiatric Nursing Practice Quiz
Psychiatric Nursing

Bong is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?

a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)

Rationale:

C is the correct answer . The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?

a. Milk
b. Orange Juice
c. Soda
d. Regular Coffee

Rationale:

D is the correct answer. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

Practice Question Test

Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?

a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea

Rationale:

D is the correct answer.Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?

a. Epilepsy
b. Myocardial Infarction
c. Renal failure
d. Respiratory failure

Rationale:

D is the correct answer. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?

a. Delusion
b. Formication
c. Flash back
d. Confusion

Rationale:

B is the correct answer. The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use

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Psychiatric Nursing Question and Rationale Part 1

This psychiatric nursing is related to perception, suicidal tendency, hallucinations, anxiety attack and cognitive development.

Psychiatric Nursing

Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:

a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy

Rationale:

C is the correct answer. Total abstinence is the only effective treatment for alcoholism.

Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as

a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms

Rationale:

A is the correct answer. Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…

a. Give her privacy
b. Allow her to urinate
c. Open the window and allow her to get some fresh air
d. Observe her

Rationale:

D is the correct answer. The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurseshould watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?

a. Provide privacy during meals
b. Set-up a strict eating plan for the client
c. Encourage client to exercise to reduce anxiety
d. Restrict visits with the family

Rationale:

B is the correct answer. Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.

A client is experiencing anxiety attack. The most appropriate nursing intervention should include?

a. Turning on the television
b. Leaving the client alone
c. Staying with the client and speaking in short sentences
d. Ask the client to play with other clients

Rationale:

C is the correct answer. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is

a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself

Rationale:

B is the correct answer.Delusion of grandeur is a false belief that one is highly famous and important.

A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?

a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision without advise

Rationale:

D is the correct answer. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?

a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior

Rationale:

A is the correct answer. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?

a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries

Rationale:

B is the correct answer. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?

a. Generates new levels of awareness
b. Assumes responsibility for her actions
c. Has maximum ability to solve problems and learn new skills
d. Her perception are based on reality

Rationale:

A is the correct answer. An adult age 31 to 45 generates new level of awareness.

Practice Question and Rationale Related to Fundamental of Nursing

Medical-Surgical Nursing Practice Quiz Part 1

This medical-surgical nursing practice is related to cancer of the breast, colostomy, rhinorrhea, testicular examinations, ventilator, and Addisonian crisis.

medical surgical nursing
Medical Surgical Nursing

A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?

a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes

Rationale:

B is the correct answer. Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retraction—not eversion—may be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass

A client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which a member of the health care team?

a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist

Rationale:

D is the correct answer. An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.

Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?

a. basilar
b. temporal
c. occipital
d. parietal

Rationale:

A is the correct answer. Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.

A male client should be taught about testicular examinations

a.when sexual activity starts
b.after age 60
c. after age 40
d. before age 20

Rationale:

D is the correct answer. Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.

Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?

A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results

Rationale:

B is the correct answer. Before weaning a client from mechanical ventilation, it’s most important to have baseline ABG levels. During the weaning process, ABGlevels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

Practice Question Test

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and arterial oxygen saturation (SaO2) 96% or better. The client most likely has

A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure

Rationale:

B is the correct answer. SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesn’t indicate the client’s overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn’t enough data to assume that the client’s problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.

For a client in Addisonian crisis, it would be very risky for a nurse to administer

A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone

Rationale:

A is the correct answer. The Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, a normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature

A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes

Rationale:

D is the correct answer. Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.

The nurse is performing wound care on afoot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?

A. Putting on sterile gloves then opening a container of sterile saline.
B. Cleaning the wound with a circular motion, moving from outer circles toward the center.
C. Changing the sterile field after sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

Rationale:

C is the correct answer. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren’t sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area—for example, from the center outward. The outer inch of a sterile field shouldn’t be considered sterile.

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?

A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein

Rationale:

C is the correct answer. Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high-calorie foods are.

Practice Question and Rationale Related to Fundamental of Nursing

Practice Question and Rationale Related to Medical-Surgical of Nursing.

Medical-Surgical Nursing Questions and Rationale Part 1

This medical-surgical nursing question is related to cerebrovascular, colostomy, celiac disease, glomerulonephritis, cerebral injury, craniotomy, lithotripsy, glucose level, ketoacidosis, and increased intracranial pressure.

medical surgical nursing
Medical Surgical Nursing

Here are the Following Question Of Medical-Surgical Nursing

After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has a left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?

a. checking stools for occult blood
b. performing range-of-motion exercises to the left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees

Rationale:

D is the correct answer. Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pinholes in the drainage bag to help relieve gas. The nurse should teach him that this action

a. destroys the odor-proof seal
b. won’t affect the colostomy system
c. is appropriate for relieving the gas in a colostomy system
d. destroys the moisture barrier seal

Rationale:

A is the correct answer. Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.

When assessing the client with celiac disease, the nurse can expect to find which of the following?

a. steatorrhea
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure

Rationale:

A is the correct answer. Because celiac disease destroys the absorbing surface of the intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclera results from elevated bilirubin levels. Clay-colored stools are seen with the biliary disease when bile flow is blocked. Celiac disease doesn’t cause widened pulse pressure.

A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because

a. reducing sodium promotes urea nitrogen excretion
b. reducing sodium improves her glomerular filtration rate
c. reducing sodium increases potassium absorption
d. reducing sodium decreases edema

Rationale:

D is the correct answer. Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn’t affected by sodium intake.

The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the

a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

Rationale:

D is the correct answer. The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.

The nurse is assessing a post craniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect

a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus

Rationale:

D is the correct answer. Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is under secretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

The nurse is providing post-procedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to

a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. Notify the physician about cloudy or foul-smelling urine
d. Report bright pink urine within 24 hours after the procedure

Rationale:

C is the correct answer. The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal because of residual stone products. Hematuria is common after lithotripsy.

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority

a. deficient fluid volume related to osmotic diuresis
b. decreased cardiac output related to elevated heart rate
c. imbalanced nutrition: Less than body requirements related to insulin deficiency
d. ineffective thermoregulation related to dehydration

Rationale:

A is the correct answer. A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition: Less than body requirements isn’t appropriate. A temperature of 100.6º F isn’t life-threatening, eliminating ineffective thermoregulation as the top priority.

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s

a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m
d. onset to be at 4 p.m. and its peak at 6 p.m

Rationale:

C is the correct answer. Regular insulin, which is short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 pm.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHg and the ICP is18 mmHg; therefore his cerebral perfusion pressure CPP is

a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg

Rationale:

A is the correct answer. CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequatecerebral perfusion to take place, the minimumgoal is 70 mmHg. The MAP is derived using the following formula:MAP = ((diastolic blood pressure x 2) + systolicblood pressure) / 3MAP = ((60 x2) + 90) / 3MAP = 70 mmHgTo find the CPP, subtract the client’s ICP fromthe MAP; in this case , 70 mmHg – 18 mmHg =52 mmHg.

Practice Question Related to Fundamental of Nursing

Fundamental of Nursing Practice Quiz Part 1

Test your knowledge about fundamental of nursing practice quiz which includes concept of nursing.

fundamentals of nursing
Fundamental of Nursing Practice Quiz

If a nurse administers an injection to a patient who refuses that injection, she has committed

a. Assault and battery
b. Negligence
c. Malpractice
d. None of the above

Rationale:

A is the correct answer. Assault is the unjustifiable attempt or threat to touch or injure another person. The battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.

If a patient asks the nurse her opinion about particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for

a. Slander
b. Libel
c. Assault
d. Respondent superior

Rationale:

A is the correct answer. Oral communication that injures an individual’s reputation is considered slander. Written communication that does the same is considered libel.

A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with

a. Defamation
b. Assault
c. Battery
d. Malpractice

Rationale:

D is the correct answer. Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale.

Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.
b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus
d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

Rationale:

A. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.

Practice Question Test

Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

a. Decreased blood pressure and heart rate and shallow respirations
b. Quiet crying
c. Immobility, diaphoresis, and avoidance of deep breathing or coughing
d. Changing position every 2 hours

Rationale:

C is the correct answer. An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.

You may also visit Fundamental of Nursing Question and Rationale Part I

Fundamental of Nursing Question and Rationale Part 1

Fundamentals of Nursing are the concept for nursing interventions and proper techniques from assessment, planning, implementation, and evaluation. Here are some questions and rationale pertaining to the fundamentals of nursing.

fundamentals of nursing

The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be

a. Maintain the patient on strict bed rest at all times
b. Maintain the patient in an orthopneic position as needed
c. Administer oxygen by Venturi mask at 24%, as needed
d. Allow a 1 hour rest period between activities

Rationale:

B is the correct answer. When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia.

The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as

a. Tachypnea
b. Eupnca
c. Orthopnea
d. Hyperventilation

Rationale:

C is the correct answer. Orthopnea is the difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort.

The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for

a. Instructing the patient about this diagnostic test
b. Writing the order for this test
c. Giving the patient breakfast
d. All of the above

Rationale:

C is the correct answer. A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test.

Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include

a. Ham and Swiss cheese sandwich on whole-wheat bread
b. Mashed potatoes and broiled chicken
c. A tossed salad with oil and vinegar and olives
d. Chicken bouillon

Rationale:

B is the correct answer. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.

The physician orders a maintenance dose of 5,000 units of subcutaneous heparin an anticoagulant daily. Nursing responsibilities for Mrs. Mitchell now include:

a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
b. Reporting an APTT above 45 seconds to the physician
c. Assessing the patient for signs and symptoms of frank and occult bleeding
d. All of the above

Rationale:

D is the correct answer. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.

The four main concepts common to nursing that appear in each of the current conceptual models are

a. Person, nursing, environment, medicine
b. Person, health, nursing, support systems
c. Person, health, psychology, nursing
d. Person, environment, health, nursing

Rationale:

D is the correct answer. The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs.

In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is

a. Love
b. b. Elimination
c. Nutrition
d. Oxygen

Rationale:

D is the correct answer. Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity, and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs.

The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?

a. Discourage them from making a decision until their grief has eased
b. Listen to their concerns and answer their questions honestly
c. Encourage them to sign the consent form right away
d. Tell them the body will not be available for a wake or funeral

Rationale:

B is the correct answer. The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. However, the family’s concerns must be addressed before members are asked to sign a consent form. The body of an organ donor is available for burial.

A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?

a. Complain to her fellow nurses
b. Wait until she knows more about the unit
c. Discuss the problem with her supervisor
d. Inform the staff that they must volunteer to rotate

Rationale:

C is the correct answer. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. In this case, the supervisor is the resource person to approach.

Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

a. Continuity of patient care promotes efficient, cost-effective nursing care
b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well
c. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
d. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Rationale:

D is the correct answer. Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.