Fundamentals of Nursing Practice Exam 2

EXPLANATION

 

✔Correct answer:

Major depression. The most common psychogenic disorder among elderly persons is major depression. Depression in the elderly can be challenging to diagnose because its symptoms can be mistaken for normal aging processes or other medical conditions. Symptoms of major depression in the elderly include persistent sadness, loss of interest in activities, fatigue, changes in sleep and appetite, and difficulty concentrating. Recognizing and treating depression in elderly patients is crucial for improving their quality of life and overall health.

Imagine an old car that isn’t running well. You might think it's just because it's old, but often, there’s a specific problem under the hood that needs fixing. Similarly, symptoms of depression in the elderly might be mistaken for “just getting old,” but they often indicate a treatable mental health condition.

Identifying and addressing mental health issues in the elderly is vital for holistic care. Depression is a significant concern due to its impact on physical health, social functioning, and overall well-being. Effective interventions can include counseling, medication, social support, and lifestyle changes to enhance mental health.

 

✘Incorrect answer options:

Sleep disturbances, including strange dreams. While sleep disturbances are common in the elderly, they are often symptoms of underlying conditions rather than a primary psychogenic disorder.

Difficulty in concentrating. Difficulty concentrating can be a symptom of various conditions, including depression, but it is not the most common psychogenic disorder itself.

Reduced appetite. Reduced appetite can be a symptom of depression and other medical conditions, but it is not a primary psychogenic disorder.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Standing. The Romberg test assesses balance and proprioception by evaluating a patient's ability to stand steadily. The correct position for conducting a Romberg test is standing. The patient should stand with their feet together, arms at their sides, and eyes open initially. The patient is then asked to close their eyes while the examiner observes for any swaying or loss of balance. This test helps identify sensory ataxia caused by issues with the dorsal columns of the spinal cord.

Think of standing on a boat with your eyes open, using visual cues to help maintain balance. Now, imagine closing your eyes; you rely more on inner senses to stay upright. The Romberg test removes visual cues to test if your inner balance mechanisms are working correctly.

The Romberg test is a critical component of the neurological examination, particularly in assessing balance and proprioception. It helps differentiate between sensory and cerebellar ataxia. Sensory ataxia, which the Romberg test primarily identifies, results from a loss of proprioceptive input, whereas cerebellar ataxia does not typically improve with visual input.

 

✘Incorrect answer options:

Sitting. The sitting position does not effectively challenge the patient's balance and proprioception, making it unsuitable for the Romberg test.

Genupectoral. The genupectoral position, or knee-chest position, is not relevant to assessing balance and proprioception in the context of the Romberg test.

Trendelenburg. The Trendelenburg position, where the patient lies supine with the head lower than the feet, is not appropriate for the Romberg test, as it does not test the patient’s ability to maintain balance while standing.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

The patient should always feed himself. This statement is incorrect regarding the care of a patient with dysphagia. Patients with dysphagia often require assistance during feeding to ensure they are swallowing safely and to prevent the risk of aspiration. Depending on the severity of their condition, they may need help from caregivers who are trained to monitor their swallowing, provide cues, and ensure they are eating and drinking safely.

Think of helping a child learn to swim. You wouldn’t leave them alone in the pool until you’re sure they can swim safely on their own. Similarly, patients with swallowing difficulties need assistance until they can safely manage their food and liquids independently.

Proper care for patients with dysphagia includes ensuring safe swallowing techniques, providing appropriate food textures, and maintaining positions that reduce the risk of aspiration. Assistance during feeding is a critical part of managing dysphagia to ensure that patients receive adequate nutrition and hydration without compromising their safety.

 

✘Correct statements:

The patient will find it easier to swallow pureed or soft foods, like custards, compared to water. This is correct as patients with dysphagia often find it easier to swallow thicker, soft, or pureed foods because they are easier to control and less likely to cause choking or aspiration compared to thin liquids.

Keeping the patient in a Fowler’s or semi-Fowler’s position can reduce the risk of aspiration while swallowing. This is correct as maintaining an upright position during and after feeding helps reduce the risk of aspiration by allowing gravity to aid in the swallowing process.

It's important to perform oral hygiene before assisting the patient with feeding. This is correct as good oral hygiene reduces the risk of infection and improves the patient’s comfort and ability to eat.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Likely dehydration. The patient's slight elevation in temperature to 99.8°F (37.7°C) after being without food or fluids for 10 hours before surgery is most likely indicative of dehydration. Dehydration can lead to a mild increase in body temperature because the body has less fluid available to dissipate heat through sweating and other cooling mechanisms. This is a common physiological response when the body is deprived of fluids for an extended period.

Imagine a car engine running without enough coolant. It may start to overheat slightly because there isn't enough fluid to regulate its temperature. Similarly, the human body can show a slight increase in temperature when it is dehydrated due to a lack of fluids.

Monitoring and interpreting vital signs are crucial in nursing care. Understanding that dehydration can cause a mild elevation in body temperature helps nurses provide appropriate interventions, such as ensuring the patient receives fluids as soon as it is safe to do so after surgery. This knowledge is particularly important in preoperative and postoperative care.

 

✘Incorrect answer options:

A possible infection. While infection can cause an elevated temperature, a slight increase to 99.8°F (37.7°C) is more likely due to dehydration in this context, given the patient’s fasting state and lack of fluid intake.

Some degree of hypothermia. Hypothermia refers to an abnormally low body temperature, which is the opposite of the elevated temperature observed in this patient.

A state of anxiety. Anxiety can cause various physiological changes, but it is less likely to cause a measurable increase in body temperature compared to dehydration. Anxiety typically results in symptoms such as increased heart rate and sweating rather than a sustained elevation in body temperature.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Provide a supportive presence, listen to their concerns, and respond truthfully to any questions they have. In a situation where a family is faced with the decision of organ donation for a loved one who has been declared brain-dead, the nurse's role is crucial in providing compassionate support. Nurse Thompson should prioritize offering a supportive presence and listening to the family's concerns. It is important to provide truthful, clear, and sensitive information in response to their questions. This approach respects the family's emotional state and helps them make an informed decision without feeling pressured. Ensuring that the family feels heard and supported is essential in helping them navigate this difficult time.

Imagine being lost in a new city and asking for directions. You would appreciate someone who takes the time to listen to your concerns, gives clear instructions, and reassures you, rather than someone who rushes you or gives incomplete information. Similarly, families in this situation need thoughtful guidance and support.

The principles of compassionate care and effective communication are fundamental in nursing, especially in sensitive situations such as organ donation discussions. Nurses should provide empathetic support, accurate information, and respect for the family's values and emotions. This helps ensure that families feel empowered and respected in making their decision.

 

✘Incorrect answer options:

Advise them to delay any decision until they have had more time to process their grief. While it is important to allow the family time to grieve, delaying the decision may not be feasible due to the time-sensitive nature of organ donation. However, Nurse Thompson should ensure the family does not feel rushed and has all the information they need.

Prompt them to quickly sign the organ donation consent forms. This approach could make the family feel pressured and overwhelmed. It is important to provide information and support, allowing the family to make a decision in their own time.

Inform them that choosing organ donation will preclude holding a wake or funeral. This statement is incorrect and could mislead the family. Organ donation typically does not interfere with the family's ability to hold a wake or funeral. Providing accurate information about the process is crucial.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursebooks.org.

EXPLANATION

 

✔Correct answer:

Alzheimer’s disease. The most frequent cause of dementia among the elderly population is Alzheimer’s disease. Alzheimer’s disease is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior. It is the leading cause of dementia, accounting for 60-80% of all dementia cases. This disease is characterized by the accumulation of amyloid plaques and neurofibrillary tangles in the brain, leading to the loss of neurons and synapses, which impairs cognitive functions.

Imagine a computer with a corrupted hard drive. Over time, it becomes slower and starts losing data until it can no longer function properly. Similarly, Alzheimer’s disease progressively damages the brain, leading to cognitive decline and memory loss.

Recognizing Alzheimer’s disease as the most common cause of dementia is crucial for healthcare providers to focus on early detection, management, and support strategies for patients and their families. Understanding its prevalence helps in developing targeted interventions and educational programs to improve the quality of life for those affected by this condition.

 

✘Incorrect answer options:

Parkinson’s disease. While Parkinson’s disease can lead to dementia, it is not the most common cause. Dementia associated with Parkinson’s typically occurs in the later stages of the disease.

Multiple sclerosis. Multiple sclerosis (MS) can cause cognitive impairments, but it is not a leading cause of dementia, especially in the elderly population.

Amyotrophic lateral sclerosis (ALS). ALS primarily affects motor neurons and muscle function. While cognitive impairments can occur, it is not a common cause of dementia.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Guaiac test.  The guaiac test, also known as the fecal occult blood test (FOBT), is a quick and immediate test used to detect hidden (occult) blood in the stool, which indicates gastrointestinal bleeding. In a patient presenting with symptoms such as nausea, vomiting, diarrhea, and severe abdominal pain, this test can help determine if there is bleeding in the GI tract. It is a simple and non-invasive test that can be performed at the bedside or in a lab, providing rapid results.

Imagine checking for a leak in a hidden pipe by using a special dye that changes color if it detects water. Similarly, the guaiac test uses a chemical reaction to detect hidden blood in the stool, indicating a potential bleed in the GI tract.

Early detection of gastrointestinal bleeding is crucial for prompt and appropriate intervention. The guaiac test helps in identifying occult blood, allowing healthcare providers to assess the severity of the bleeding and initiate necessary treatment. Understanding and utilizing appropriate diagnostic tools is essential in managing and preventing complications associated with GI bleeding.

 

✘Incorrect answer options:

Complete blood count. While a complete blood count (CBC) can indicate anemia or low hemoglobin levels associated with chronic or significant blood loss, it is not an immediate test to confirm active GI bleeding.

Monitoring vital signs. Monitoring vital signs is important for assessing the patient's overall condition and response to bleeding, such as detecting signs of shock (e.g., low blood pressure, increased heart rate), but it does not specifically confirm the presence of GI bleeding.

Measuring abdominal girth. Measuring abdominal girth is useful for assessing distension and fluid accumulation in the abdomen, but it does not provide direct evidence of gastrointestinal bleeding.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Stimulation of the parasympathetic nervous system. The parasympathetic nervous system, when stimulated, typically causes a decrease in heart rate (bradycardia) rather than an increase (tachycardia). It works to conserve energy and promote relaxation by slowing down the heart rate and reducing the force of cardiac contractions. This is in contrast to the sympathetic nervous system, which increases heart rate and cardiac output in response to stress or physical activity.

Think of the parasympathetic nervous system as a brake pedal for your heart, slowing it down and helping you relax. Conversely, the sympathetic nervous system is like the gas pedal, speeding things up when you need to be active or alert.

Understanding the autonomic nervous system is crucial for recognizing how various factors influence heart rate. The parasympathetic nervous system, through the vagus nerve, exerts a calming effect on the heart, slowing it down. This mechanism is important in maintaining homeostasis and conserving energy during periods of rest.

 

✘Incorrect answer options:

Fever. Fever can cause tachycardia because the body increases the heart rate to meet the higher metabolic demands and to help dissipate heat.

Exercise. Exercise naturally increases heart rate as the body requires more oxygen and nutrients to be delivered to the muscles.

Stimulation of the sympathetic nervous system. The sympathetic nervous system increases heart rate and cardiac output to prepare the body for 'fight or flight' responses during stress or physical activity.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Ineffective airway clearance related to thick, tenacious secretions. The most appropriate nursing diagnosis for this patient is "Ineffective airway clearance related to thick, tenacious secretions." COPD exacerbations often result in increased production of mucus that is thick and difficult to expectorate, leading to airway obstruction and difficulty breathing. This diagnosis directly addresses the primary issue affecting the patient's respiratory function.

Think of trying to clear a clogged drain. If the clog (mucus) is thick and sticky, it blocks the flow (airway), making it hard for water (air) to pass through. Clearing the clog is essential for restoring normal flow.

Effective nursing care for patients with COPD focuses on maintaining airway patency, promoting effective coughing, and managing secretions. Interventions may include hydration, chest physiotherapy, and medications to thin mucus and facilitate its removal. Recognizing and addressing the primary issue of thick secretions helps improve the patient's breathing and overall comfort.

 

✘Incorrect answer options:

Ineffective airway clearance related to dry, hacking cough. While a dry, hacking cough is a symptom, the primary issue here is the presence of thick, tenacious secretions that obstruct the airway, not the cough itself.

Ineffective individual coping with COPD. This diagnosis focuses on the patient's emotional and psychological adaptation to their chronic illness. While important, it does not address the immediate physical issue of airway clearance.

Pain related to immobilization of affected leg. This diagnosis is unrelated to the patient's current symptoms and condition, as there is no mention of leg pain or immobilization.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Fractures of the hip. The most common injury among elderly persons is fractures of the hip. Hip fractures are particularly prevalent in this population due to factors such as osteoporosis, decreased bone density, and the increased likelihood of falls. These fractures can have severe consequences, including prolonged immobility, decreased independence, and higher mortality rates. Preventing hip fractures involves strategies such as fall prevention, bone health maintenance, and safe environments.

Think of an old tree that has become brittle over time. A strong wind (a fall) can easily break its branches (bones), especially the thicker ones like the main branches (hips). Ensuring the tree is protected from strong winds and well-supported can prevent these breaks.

Understanding the common injuries in the elderly population allows healthcare providers to focus on preventive measures and early interventions. Emphasizing fall prevention, home safety modifications, and bone-strengthening activities can significantly reduce the incidence of hip fractures and improve the overall health and quality of life for elderly patients.

 

✘Incorrect answer options:

Atherosclerotic changes in the blood vessels. While common in the elderly, atherosclerosis is a condition rather than an injury.

Higher incidence of gallbladder disease. Gallbladder disease is also more prevalent in the elderly but does not represent an injury.

Frequent urinary tract infections. UTIs are common in the elderly but are infections, not injuries.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Drinks that contain caffeine, like coffee and soft drinks. Caffeine is a known diuretic, meaning it increases urine production by the kidneys. Drinks containing caffeine, such as coffee and certain soft drinks, can lead to increased urine output by promoting the excretion of sodium and water from the body. This diuretic effect can influence hydration levels and the overall balance of fluids in the body.

Imagine caffeine as a key that unlocks the kidneys, prompting them to release more water, much like opening a faucet. This results in more frequent trips to the bathroom as the body expels excess fluid.

Understanding the diuretic effects of certain substances is important for managing fluid balance and hydration. Caffeine, found in various beverages, can have a significant impact on urine production. People who consume large amounts of caffeine should be aware of its diuretic properties and ensure they stay adequately hydrated to compensate for the increased fluid loss.

 

✘Incorrect answer options:

Root vegetables such as beets. While beets have many health benefits, they are not known for significantly increasing urine production.

Medications for urinary pain relief. These medications may help alleviate discomfort but do not typically increase urine production.

Anti-diarrheal mixtures containing kaolin and pectin. These mixtures are designed to reduce diarrhea and do not have a diuretic effect.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Malpractice. The nurse could be charged with malpractice due to the incident where the 3-month-old infant fell off the scale and sustained a skull fracture. Malpractice refers to professional negligence by a healthcare provider that results in harm to the patient. In this scenario, the nurse failed to provide the standard of care expected, which includes ensuring the safety of a vulnerable patient (the infant) at all times. By momentarily turning away to answer a phone call and not securing the infant, the nurse's actions directly led to the injury.

Think of a lifeguard responsible for watching swimmers in a pool. If the lifeguard looks away to answer a phone call and a swimmer gets injured during that moment, the lifeguard would be held responsible for not performing their duty of constant vigilance. Similarly, the nurse's momentary distraction led to the infant's injury, constituting malpractice.

Malpractice in nursing involves a breach of duty that results in patient harm. Nurses have a legal and ethical obligation to provide continuous and vigilant care, especially to high-risk patients like infants. This scenario highlights the importance of maintaining focus on patient safety and the potential legal consequences of failing to do so.

 

✘Incorrect answer options:

Defamation. Defamation involves making false and damaging statements about someone, either orally (slander) or in writing (libel). This scenario does not involve false statements but rather a lapse in patient care.

Assault. Assault refers to the threat or attempt to make physical contact with someone without their consent, causing fear of harm. The nurse's actions did not involve threats or attempts to cause harm.

Battery. Battery involves intentional physical contact with someone without their consent. The nurse did not intentionally harm the infant but rather failed to provide adequate supervision.

 

References

• Guido, G. W. (2014). Legal and Ethical Issues in Nursing (6th ed.). Pearson.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

All of the choices. All the listed positions—genupectoral, Sims', and horizontal recumbent—are appropriate for a rectal examination.

• Genupectoral (knee-chest) position involves the patient kneeling on the exam table with their chest and face down, which allows good access to the rectal area.
• Sims' position involves the patient lying on their left side with their right knee drawn up towards the chest and left leg extended. This position provides good access and is often used for rectal exams and enemas.
• Horizontal recumbent (left lateral) position involves the patient lying on their back or side. When used for a rectal exam, the left lateral position (left side-lying) is often referred to, which also allows proper access to the rectal area.

Think of inspecting the underside of a car. You might use different positions or angles to get the best view and access to different parts. Similarly, these different positions allow the healthcare provider to have the best access and visibility for performing a thorough rectal examination.

The choice of position for a rectal examination depends on the patient's condition, the specific procedure being performed, and the comfort of both the patient and the examiner. Each position provides adequate access to the rectal area while maintaining patient comfort and dignity as much as possible. Proper positioning ensures that the examination can be conducted effectively and safely.

 

✘Incorrect answer options:

Since the correct answer is "All of the choices," the incorrect options would be any one of the individual positions if they were chosen in isolation. Each of the three positions listed—genupectoral, Sims', and horizontal recumbent—is appropriate for a rectal examination when considered on its own.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

54. The pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. For Mr. Jensen, with a blood pressure of 150/96 mmHg, the calculation is as follows:

Pulse Pressure = Systolic Pressure - Diastolic Pressure = 150 - 96 = 54 mmHg.

Pulse pressure is an important indicator of cardiovascular health. A higher pulse pressure can indicate increased risk for heart problems, but in this case, a pulse pressure of 54 mmHg is considered within a manageable range, although still elevated.

Imagine measuring the height difference between two points on a hill (systolic pressure) and a valley (diastolic pressure). The difference in height (pulse pressure) helps you understand how steep the hill is. Similarly, the difference between the systolic and diastolic pressure helps assess the strain on the heart.

Pulse pressure is the difference between the systolic and diastolic blood pressure readings and provides insight into the elasticity of the arteries. A normal pulse pressure range is typically between 30 and 50 mmHg. Elevated pulse pressure can indicate increased arterial stiffness and is associated with higher cardiovascular risk, especially in hypertensive patients like Mr. Jensen.

 

✘Incorrect answer options:

96. This option mistakenly considers the diastolic pressure alone as the pulse pressure, which is incorrect.

150. This option mistakenly considers the systolic pressure alone as the pulse pressure, which is incorrect.

246. This option adds the systolic and diastolic pressures together, which is not how pulse pressure is calculated.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Suppression of the respiratory drive triggered by low oxygen levels. In patients with chronic obstructive pulmonary disease (COPD), the respiratory drive can be primarily triggered by low oxygen levels (hypoxic drive), rather than the normal drive triggered by high carbon dioxide levels. Administering too much oxygen can suppress this hypoxic drive, leading to a decrease in respiratory rate and hypoventilation, which can result in elevated carbon dioxide levels (hypercapnia) and respiratory acidosis. Therefore, it is crucial to administer the prescribed amount of oxygen to avoid suppressing the patient's respiratory drive and causing complications.

Think of a thermostat-controlled heating system in a house that kicks in only when the temperature drops too low. If you suddenly introduce a constant external heat source, the thermostat stops working correctly because it no longer detects the drop in temperature. Similarly, in COPD patients, their bodies rely on low oxygen levels to trigger breathing. Giving too much oxygen can disrupt this natural trigger, leading to decreased breathing effort and potentially dangerous levels of carbon dioxide in the blood.

Managing oxygen therapy in COPD patients involves a careful balance to ensure adequate oxygenation without suppressing the respiratory drive. Monitoring oxygen saturation and following the prescribed oxygen flow rate are critical to avoid complications such as hypercapnia and respiratory failure.

 

✘Incorrect answer options:

Cardiac arrest caused by an increase in partial pressure of carbon dioxide (PaCO2) in the arterial blood. While elevated PaCO2 can lead to serious complications, cardiac arrest is not the direct concern related to oxygen administration in COPD patients.

Circulatory overload resulting from hypervolemia. Hypervolemia and circulatory overload are not directly related to oxygen therapy but rather to fluid management.

Overstimulation of the respiratory system. Overstimulation is not the concern with oxygen therapy; rather, the concern is the suppression of the respiratory drive due to excessive oxygen.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Orthopnea Orthopnea is a type of breathing difficulty that occurs when a person is lying flat and is relieved when the person sits or stands up. Mr. Adams experiences increased difficulty breathing while lying down and finds relief when the head of the bed is elevated, which is characteristic of orthopnea. This condition is often seen in patients with heart failure or other conditions that cause fluid buildup in the lungs, making it easier for them to breathe when they are in an upright position.

Think of trying to breathe easily while someone is gently pressing on your chest. It’s harder to take a deep breath, but when the pressure is relieved, breathing becomes easier. Similarly, lying flat can make it harder for some patients to breathe, but sitting up can relieve that pressure and make breathing easier.

In nursing, understanding different types of breathing patterns is essential for assessing and managing respiratory conditions effectively. Orthopnea specifically indicates that the patient may have underlying cardiac or pulmonary issues that need to be addressed. By documenting the presence of orthopnea accurately, Nurse Anderson ensures that Mr. Adams receives the appropriate interventions and monitoring for his condition.

 

✘Incorrect answer options:

Tachypnea Tachypnea refers to an abnormally rapid breathing rate. While it indicates a problem with breathing, it does not specifically describe difficulty breathing that is relieved by sitting up.

Eupnea Eupnea is the term for normal, unlabored breathing. This does not apply to Mr. Adams' situation as he is experiencing respiratory distress.

Hyperventilation Hyperventilation involves rapid or deep breathing, often leading to a decrease in carbon dioxide levels in the blood. It is not related to the positional breathing difficulty experienced by Mr. Adams.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

All of the choices. All of the mentioned changes result from aging and impact the cardiovascular system in older adults:

• Higher peripheral resistance in the blood vessels: As people age, their blood vessels often become less elastic and more rigid, leading to increased peripheral resistance. This means the heart has to work harder to pump blood through the vessels.
• Reduced blood flow: Aging can cause a reduction in overall blood flow due to changes in the vascular system, such as narrowed or blocked arteries. This reduced blood flow can impact the delivery of oxygen and nutrients to tissues.
• Increased workload on the left ventricle: With increased peripheral resistance and reduced elasticity of the blood vessels, the left ventricle has to pump harder to maintain adequate blood circulation. Over time, this increased workload can lead to hypertrophy (thickening) of the left ventricle and potentially contribute to heart failure.

Imagine a water pump system where the pipes become narrower and more rigid over time. The pump (heart) has to work harder to push water (blood) through the system, leading to more wear and tear on the pump and reduced water flow to the end users (tissues).

Understanding the physiological changes in the cardiovascular system due to aging is essential for providing appropriate care and interventions for older adults. These changes necessitate monitoring and managing cardiovascular health to prevent complications and maintain overall well-being in the elderly population.

 

✘Incorrect answer options:

Since all the listed changes (higher peripheral resistance, reduced blood flow, and increased workload on the left ventricle) are correct, each option alone would not provide a complete understanding of the comprehensive cardiovascular changes that occur with aging.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Muscle weakness.  The most significant symptom of hypokalemia that Nurse Thompson should be aware of is muscle weakness. Hypokalemia, which is a low level of potassium in the blood, can affect muscle function because potassium is essential for normal muscle cell function. Severe muscle weakness can be particularly concerning as it may progress to paralysis, including respiratory muscles, leading to respiratory failure.

Imagine a car battery that is running low on power. Just as a low battery makes it hard for the car to start and run efficiently, low potassium levels make it difficult for muscles to contract and function properly, leading to weakness.

Monitoring for symptoms of hypokalemia is critical in hospitalized patients, especially those on diuretics or with conditions that predispose them to electrolyte imbalances. Recognizing and addressing muscle weakness promptly can prevent serious complications and ensure appropriate treatment is administered.

 

✘Incorrect answer options:

Lethargy. While lethargy can be a symptom of hypokalemia, it is not as specific or significant as muscle weakness in indicating the severity of the condition.

Increased pulse rate and blood pressure. Hypokalemia can cause changes in heart function, but increased pulse rate and blood pressure are not the most significant indicators.

Muscle irritability. Muscle irritability or cramps can occur with hypokalemia, but muscle weakness is a more critical and significant symptom to monitor.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Less than 30 ml/hour. Nurse Wilson should alert the physician if the patient's urine output is less than 30 ml/hour. This threshold is critical because it indicates potential renal insufficiency or failure. Consistently low urine output can be a sign of decreased kidney function, dehydration, or other serious medical conditions that require immediate attention.

Think of the kidneys like a coffee machine. If the machine is not producing the usual amount of coffee (urine), it might be clogged or malfunctioning. Similarly, low urine output can indicate that the kidneys are not working properly and need attention.

Monitoring urine output is a key component of assessing renal function and fluid balance. A urine output of less than 30 ml/hour is concerning because it suggests that the kidneys are not filtering blood effectively, which could lead to an accumulation of waste products and fluid imbalances in the body. Immediate intervention is necessary to identify and address the underlying cause.

 

✘Incorrect answer options:

64 ml in 2 hours. This output averages 32 ml/hour, which is above the critical threshold of 30 ml/hour and does not immediately indicate a severe problem.

90 ml in 3 hours. This output averages 30 ml/hour, which is at the lower threshold but still within an acceptable range. Close monitoring is required, but immediate physician notification may not be necessary unless it continues to drop.

125 ml in 4 hours. This output averages 31.25 ml/hour, which is above the critical threshold and generally considered acceptable.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Lack of movement, sweating, and avoiding deep breaths or coughing. In the context of cultural competence, it is important to recognize that patients from different cultural backgrounds may express pain differently. Asian patients may not verbally express their pain and may instead show non-verbal signs such as lack of movement, sweating, and avoiding deep breaths or coughing. These behaviors can be indicative of discomfort and pain, especially after abdominal surgery. The staff should be attentive to these subtle signs to provide appropriate pain management and support.

Think of someone trying to hide their discomfort after getting a splinter. They might not say anything, but you might notice they avoid using that hand, have a tense expression, or are sweating from the discomfort. Similarly, patients from certain cultural backgrounds might not vocalize their pain but show it through their actions and body language.

Cultural competence in nursing involves understanding and respecting the diverse ways patients express pain and discomfort. Recognizing non-verbal cues and providing culturally sensitive care ensures that all patients receive appropriate and effective pain management. It is essential for healthcare providers to be aware of and responsive to these differences to avoid underestimating or misinterpreting a patient's pain.

 

✘Incorrect answer options:

Lowered blood pressure and heart rate, along with shallow breathing. These are not typical signs of postoperative pain. Pain often results in elevated blood pressure and heart rate due to the body's stress response.

Quiet crying. While this could be a sign of pain, it is not specific to the cultural context of the scenario provided. Many Asian patients might not vocalize their pain in this manner.

Regularly changing positions every two hours. Regularly changing positions can be a part of routine postoperative care to prevent complications such as pressure ulcers, but it is not necessarily an indicator of pain.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Giger, J. N., & Davidhizar, R. (2012). Transcultural Nursing: Assessment and Intervention (6th ed.). Mosby.

EXPLANATION

 

✔Correct answer:

Initiating with auscultation, proceeding to percussion, and concluding with palpation. The correct sequence for an abdominal assessment is to start with auscultation, then proceed to percussion, and conclude with palpation. This order is important to ensure that bowel sounds are not altered by the physical manipulation of the abdomen, which can occur if percussion or palpation is done first. Auscultation allows the nurse to listen to the natural state of bowel sounds without interference, while percussion helps to assess the presence of fluid, gas, or masses, and palpation is used to detect tenderness, distention, or abnormalities.

Imagine checking the level of a liquid in a bottle. First, you listen to hear if it's full (auscultation), then you gently tap the sides to get a sense of the volume (percussion), and finally, you lightly shake the bottle to confirm the contents (palpation). This sequence ensures you get the most accurate information without disturbing the liquid inside too early.

Proper technique in physical assessment is crucial for accurate diagnosis and patient care. By following the correct sequence of auscultation, percussion, and palpation, nurses can gather accurate information about the patient's abdominal condition without causing unnecessary discomfort or altering natural bowel sounds. This approach aligns with best practices in nursing and ensures comprehensive and effective patient assessments.

 

✘Incorrect answer options:

Starting with tympanic percussion, followed by measuring abdominal girth, and then inspection. This sequence is incorrect as it does not follow the standard order of abdominal assessment techniques, and percussion should not precede auscultation.

First assessing for distention, tenderness, and discoloration around the umbilicus. While these assessments are important, they do not follow the proper sequence of techniques for an abdominal assessment.

Beginning with percussions, followed by palpation, and ending with auscultation. This order is incorrect because palpation before auscultation can alter bowel sounds, leading to inaccurate assessment findings.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

Person, environment, health, nursing. The four main concepts that are universally included in all current nursing conceptual models are person, environment, health, and nursing. These concepts form the foundational framework for understanding and practicing nursing.

• Person refers to the recipient of care, including individuals, families, and communities.
• Environment encompasses all external factors that can affect the person, including physical, social, and cultural elements.
• Health is a dynamic state of being that varies along a continuum from wellness to illness.
• Nursing involves the actions and interventions provided by the nurse to care for the person within their environment to achieve optimal health outcomes.

These concepts are interrelated and provide a comprehensive view of the factors influencing nursing practice and patient care.

Think of nursing as a garden where the person is the plant, the environment is the soil and climate, health is the plant’s growth and vitality, and nursing is the gardener’s care and interventions to ensure the plant thrives.

These four concepts are integral to developing nursing theories and models, guiding nursing practice, and ensuring holistic patient care. They help nurses assess, plan, implement, and evaluate care effectively, taking into account all aspects of a patient's life and well-being.

 

✘Incorrect answer options:

A. Person, nursing, environment, medicine. This option is incorrect because medicine is not considered one of the four main concepts in nursing models. Nursing models focus on the broader scope of nursing care rather than the medical model of disease and treatment.

B. Person, health, nursing, support systems. While support systems are important in patient care, they are considered part of the environment rather than a separate foundational concept in nursing models.

C. Person, health, psychology, nursing. Psychology is an important aspect of health and well-being but is not one of the four foundational concepts in nursing models. The environment is a broader concept that encompasses psychological factors.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Position the patient in an orthopneic position when required. The orthopneic position is a body position designed to relieve dyspnea (difficulty breathing) by allowing maximal chest expansion. This position involves sitting the patient up and leaning slightly forward, often with arms supported on a table or pillows. This posture helps the diaphragm move more freely, which can ease breathing in patients experiencing shortness of breath. For Mr. Brooks, who is experiencing dyspnea, positioning him in an orthopneic position is a priority because it can provide immediate relief and improve oxygenation without the need for additional equipment or interventions.

Imagine trying to breathe through a small straw while lying down versus sitting up. When you're sitting up, your lungs have more room to expand, making it easier to take in more air, similar to how the orthopneic position helps patients with breathing difficulties.

The orthopneic position is a fundamental non-invasive intervention in respiratory care, particularly for patients with chronic obstructive pulmonary disease (COPD) or heart failure. It leverages gravity to optimize lung function, thereby improving ventilation and gas exchange. Implementing this technique demonstrates the nurse's ability to apply basic anatomical and physiological principles to enhance patient comfort and outcomes.

 

✘Incorrect answer options:

The patient must remain on strict bed rest at all times. While bed rest might be appropriate in some cases, it can contribute to deconditioning and exacerbate dyspnea over time. Additionally, complete bed rest is not necessary unless specified for specific medical reasons, and it does not directly address the immediate issue of improving breathing.

Administer oxygen via a Venturi mask at 24% as necessary. Administering oxygen can be beneficial for patients with dyspnea, but it should be based on a physician’s order and specific clinical parameters such as oxygen saturation levels. It is an important intervention but not the first priority unless hypoxia is confirmed.

Ensure the patient has a 1-hour rest period between activities. Providing rest periods is important for energy conservation in patients with respiratory issues. However, it does not directly address the immediate relief of dyspnea. The orthopneic position offers more immediate symptomatic relief.

 

References

• Potter, P.A., Perry, A.G., Stockert, P., & Hall, A. (2017). Fundamentals of Nursing (9th ed.). Elsevier.
• Berman, A., Snyder, S., Frandsen, G., & Kozier, B. (2016). Kozier & Erb's Fundamentals of Nursing (10th ed.). Pearson.

EXPLANATION

 

✔Correct answer:

Accompany the patient during his walk. Nurse Martinez should accompany the patient during his first walk outside his room. Although the patient appears steady on his feet and his vision is unaffected, it is essential to provide support and supervision during his initial attempt at walking post-surgery. This approach ensures the patient's safety, allows the nurse to monitor for any signs of dizziness, weakness, or other complications, and provides reassurance to the patient.

Imagine guiding someone who is walking on ice for the first time. Even if they seem steady, having someone there for support can prevent falls and boost their confidence. Similarly, accompanying the patient ensures a safe and confident walk.

Post-surgical patients may experience various issues, such as fatigue, balance problems, or pain, which can affect their mobility. Providing direct support during their first attempts at walking helps prevent falls and promotes recovery. This intervention aligns with the principles of patient safety and effective postoperative care.

 

✘Incorrect answer options:

Suggest that the patient walk in the hallway by himself. This option is not recommended as it does not provide the necessary support and supervision needed for a patient's first walk post-surgery.

Advise the patient to wait a few more days before walking in the hall. Unless there are specific medical reasons to delay ambulation, encouraging early mobilization is important for recovery. Waiting unnecessarily could delay the patient's progress.

Request a consultation with a physical therapist before permitting the patient to walk. While consulting a physical therapist can be beneficial, it is not typically necessary for a nurse to accompany the patient on a simple walk, especially if the patient is stable and the nurse can provide immediate support.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

All of the mentioned interventions.  All of the mentioned interventions best promote patient safety. Each of these actions addresses a critical aspect of ensuring the patient's well-being and safety during their hospital stay:

• Evaluate the patient's ability to walk and move from the bed to a chair: Assessing the patient's mobility helps prevent falls and injuries by identifying those who need assistance or mobility aids.
• Explain and demonstrate the call bell system to the patient: Ensuring the patient knows how to use the call bell system allows them to quickly alert staff if they need help, which is crucial for preventing accidents and addressing their needs promptly.
• Verify that the patient is wearing their identification band: Proper identification ensures that patients receive the correct medications, treatments, and care, preventing errors related to patient misidentification.

Think of patient safety as a multi-layered approach like the safety features in a car. Seat belts (identification bands) keep passengers secure, knowing how to use the horn (call bell system) alerts others in emergencies, and checking tire pressure (evaluating mobility) prevents accidents. Each feature contributes to overall safety.

Comprehensive patient safety involves multiple interventions that together create a safer environment. By addressing mobility, communication, and proper identification, nurses can significantly reduce the risk of adverse events and improve patient outcomes.

 

✘Incorrect answer options:

Since all interventions listed are crucial for patient safety, any single option alone would not fully address the comprehensive approach required for ensuring patient safety during a hospital stay.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Assault and battery.  The nurse's action of administering an injection to a patient who explicitly refuses it is classified as assault and battery. Legally, assault refers to the threat or attempt to make physical contact with a person without their consent, while battery refers to the actual physical contact or harm. In this scenario, the patient's explicit refusal means they have not given consent, and the nurse's action violates the patient's autonomy and right to refuse treatment. This breach of patient rights is not only ethically wrong but also legally actionable as assault and battery.

Imagine someone explicitly saying they do not want a hug, but you hug them anyway. This unwanted physical contact against their will is similar to the nurse administering an injection without the patient's consent, constituting assault and battery.

Patient autonomy is a core principle in nursing ethics and legal standards, emphasizing the patient's right to make informed decisions about their care. Respecting a patient's decision, including their right to refuse treatment, is essential. Violating this principle undermines trust, patient safety, and the ethical foundation of nursing practice.

 

✘Incorrect answer options:

Negligence. Negligence refers to the failure to provide the standard of care that a reasonably prudent person would provide in a similar situation, leading to harm. Administering an injection without consent is more than negligence; it is a direct violation of the patient's rights.

Malpractice. Malpractice is a type of negligence where a professional fails to perform their duties competently, resulting in harm to the patient. While serious, malpractice does not capture the intentional aspect of administering treatment against a patient's explicit refusal.

None of the choices. This is incorrect because the correct classification of the action is assault and battery, as it involves unauthorized physical contact.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Guido, G. W. (2014). Legal and Ethical Issues in Nursing (6th ed.). Pearson.

EXPLANATION

 

✔Correct answer:

Slander. The nurse's comment about the physician being incompetent constitutes slander. Slander is a form of defamation that involves making false and damaging verbal statements about another person. In this scenario, the nurse’s verbal statement could harm the physician's reputation and professional standing, making the nurse legally liable for slander if the statement is false and damaging.

Imagine someone telling others that a chef at a restaurant is terrible and ruins every dish, even though it’s not true. This could harm the chef’s reputation and business, just as the nurse’s comment could harm the physician’s professional reputation.

Professional conduct in healthcare includes maintaining respect and professionalism when discussing colleagues. Defamation laws protect individuals from false statements that could damage their reputation. Nurses must communicate professionally and avoid making unfounded negative comments about colleagues to maintain a respectful and supportive work environment.

 

✘Incorrect answer options:

Libel. Libel refers to written defamation, where false and damaging statements are made in writing or other permanent forms. Since the nurse's statement was verbal, not written, it is not classified as libel.

Assault. Assault involves the threat or attempt to make physical contact without consent, leading to fear of harm. The nurse’s comment does not involve physical threats or contact, so it does not constitute assault.

Respondeat superior. Respondeat superior is a legal doctrine holding employers liable for the actions of their employees performed within the scope of their employment. While it might apply to the nurse’s employer, it does not directly address the nurse’s personal liability for the defamatory statement.

 

References

• Guido, G. W. (2014). Legal and Ethical Issues in Nursing (6th ed.). Pearson.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Pedal pulse. The absence of a pedal pulse might not be considered a significant finding upon a patient's hospital admission. While it is important to assess all peripheral pulses, the pedal pulse can sometimes be difficult to palpate due to various factors such as peripheral vascular disease, edema, or anatomical variations. In the absence of other signs of poor circulation, such as cyanosis or pain, the absence of a pedal pulse alone is not immediately alarming and might require further assessment using Doppler ultrasound for confirmation.

Imagine trying to find a weak radio signal in a remote area. Sometimes the signal is hard to detect, but it doesn’t necessarily mean the radio station isn’t broadcasting. Similarly, a pedal pulse can be hard to detect but might still be present and require more sensitive equipment to find.

Proper assessment of peripheral pulses is crucial in evaluating a patient’s circulatory status. However, certain pulses, like the pedal pulse, can be less palpable due to individual variations. Comprehensive assessment, including checking other pulse points and using appropriate tools, ensures accurate evaluation of the patient’s vascular health.

 

✘Incorrect answer options:

Apical pulse. The absence of an apical pulse would be significant and alarming, indicating a possible severe cardiac issue, as it reflects the heart’s actual beating.

Radial pulse. The radial pulse is easily accessible and commonly assessed. Its absence could indicate significant circulatory problems in the arm or more centrally.

Femoral pulse. The femoral pulse is a major pulse point in the body. Its absence can indicate serious central or peripheral vascular issues and requires immediate attention.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

“I understand this is hard for you, but your hair will grow back after the chemotherapy is completed.”  This response acknowledges Mrs. Johnson's feelings, validates her emotions, and provides reassurance about the temporary nature of the hair loss. It shows empathy and understanding of her emotional distress while also giving her hope that the situation is not permanent.

Imagine someone feeling sad about losing a cherished item. A comforting response would acknowledge their sadness and reassure them that they will be able to replace the item in the future.

Emotional support is a crucial aspect of nursing care, especially when discussing difficult topics like chemotherapy-induced hair loss. By acknowledging the patient's emotions and providing factual information, the nurse can help the patient cope with the situation more effectively.

 

✘Incorrect answer options:

“Don’t be concerned. This is only a temporary situation.” While it is true that hair loss is temporary, this response may come across as dismissive of the patient's feelings.

“Why are you crying? I haven't even shared the most difficult part yet.” This response is insensitive and invalidates the patient's current emotional experience, potentially increasing her distress.

“Your hair looks really lovely.” Although intended to be complimentary, this response does not address the patient's concerns about hair loss and can seem out of touch with her emotional state.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Assessing the apical pulse. Palpating the midclavicular line is specifically used for assessing the apical pulse. The apical pulse is located at the apex of the heart, which is found in the fifth intercostal space at the midclavicular line. This assessment involves auscultating or palpating this area to count the heartbeats for a full minute to determine the heart rate and rhythm accurately.

Imagine finding the exact spot on a map where two lines intersect. Similarly, finding the apical pulse requires locating the point where the fifth intercostal space (horizontal line) meets the midclavicular line (vertical line).

Assessing the apical pulse is crucial for evaluating cardiac function, especially in patients with irregular heart rhythms or conditions affecting the heart. The midclavicular line provides a consistent anatomical landmark for locating the apex of the heart, ensuring accurate and reliable assessments.

 

✘Incorrect answer options:

Recording baseline vital signs. Recording baseline vital signs involves measuring temperature, blood pressure, respiratory rate, and heart rate, but it does not specifically relate to the technique of palpating the midclavicular line.

Measuring systolic blood pressure. Measuring systolic blood pressure is typically done using a sphygmomanometer and stethoscope at the brachial artery, not the midclavicular line.

Determining respiratory rate. Determining respiratory rate involves counting breaths per minute by observing the chest or abdomen, not palpating the midclavicular line.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

Young adulthood. Young adulthood is the period that typically does not require an increased intake of Vitamin C compared to other life stages. During infancy, childhood, and pregnancy, the body has higher demands for Vitamin C to support growth, development, and overall health. Pregnant women, in particular, need more Vitamin C to support fetal development and maternal health.

Think of Vitamin C as a key ingredient in building a house. During periods of rapid growth or construction (like infancy, childhood, and pregnancy), you need more of this ingredient. In young adulthood, when the house (body) is already built and just needs maintenance, you don't need as much.

Vitamin C is crucial for the growth, development, and repair of all body tissues, and it is particularly important during periods of rapid growth or physiological stress. While maintaining adequate Vitamin C intake is important at all life stages, the requirement does not typically increase significantly during young adulthood unless there are specific health conditions or lifestyle factors that increase the need.

 

✘Incorrect answer options:

Infancy. Infants require additional Vitamin C to support their rapid growth and development.

Childhood. Children need increased Vitamin C to support their growth, immune function, and overall development.

Pregnancy. Pregnant women require higher levels of Vitamin C to support fetal development and maintain their own health.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Grodner, M., Escott-Stump, S., & Dorner, S. (2016). Nutritional Foundations and Clinical Applications (6th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

A holistic approach that fosters a therapeutic relationship, continuity of care, and efficient nursing services. The most effective principle in enhancing satisfaction for both patients and nurses is a holistic approach that fosters a therapeutic relationship, continuity of care, and efficient nursing services. This principle ensures that patients receive comprehensive and personalized care from a consistent caregiver, which enhances trust and communication. For nurses, it provides a deeper connection with their patients, leading to greater job satisfaction and a sense of fulfillment. By integrating these elements, both patient outcomes and nurse engagement improve, ultimately leading to higher satisfaction levels.

Think of primary nursing as having a dedicated gardener for your personal garden. This gardener knows every plant, the specific care each one needs, and can provide consistent, personalized attention to ensure each plant thrives. The gardener's ongoing relationship with the garden allows for timely interventions, nurturing, and adjustments, leading to a flourishing garden. Similarly, a dedicated nurse familiar with a patient's needs can provide continuous, personalized care, building trust and ensuring the patient's health blooms.

Primary nursing is based on the concept of holistic, patient-centered care. It emphasizes the importance of a consistent caregiver who is responsible for the patient's entire care plan. This continuity of care improves the therapeutic relationship, making patients feel more secure and understood. It also allows nurses to practice autonomously and take ownership of patient outcomes, enhancing their professional satisfaction and engagement.

 

✘Incorrect answer options:

The promotion of continuous patient care that ensures efficient, cost-effective nursing services. While important, this principle focuses more on efficiency and cost-effectiveness rather than the holistic and relational aspects that enhance satisfaction.

The delegation of autonomy and authority for planning to a nurse familiar with the patient. Autonomy and authority are crucial, but without the holistic approach and continuity of care, they do not fully address the relational and satisfaction aspects.

The clarity of accountability when one nurse oversees the entire care plan and its execution. Accountability is essential for ensuring high-quality care, but it alone does not enhance the therapeutic relationship or continuity of care that drive satisfaction.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Yoder-Wise, P. S. (2019). Leading and Managing in Nursing (7th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Approach and discuss the staffing issue with her direct supervisor. As the head nurse, Nurse Gomez holds a leadership position with the responsibility to ensure adequate staffing levels to provide safe and effective patient care. The most appropriate action is to discuss the staffing issue with her direct supervisor. This allows for a formal, professional approach to addressing the problem, ensuring that the concerns are documented and can be escalated through the appropriate channels. It also provides an opportunity to collaboratively explore solutions, such as hiring additional staff, adjusting schedules, or seeking temporary staffing support.

Think of Nurse Gomez as the captain of a ship who notices that they are short on crew members during a crucial shift. She wouldn’t just mention it casually to other crew members or wait to see if it resolves itself. Instead, she would bring it to the attention of the ship’s management to get the necessary support and ensure the ship runs smoothly.

Effective leadership in nursing involves recognizing issues that impact patient care and addressing them through proper channels. Communication with supervisors is key in addressing systemic issues like staffing shortages. It ensures that concerns are managed at an administrative level where policies and resources can be allocated to resolve the problem. This approach also aligns with the principles of advocacy and patient safety, central to nursing practice.

 

✘Incorrect answer options:

Voice her concerns informally to her fellow nursing colleagues. While discussing with colleagues can provide immediate emotional support, it is not an effective strategy to resolve staffing issues. It does not ensure that the concerns reach those with the authority to make necessary changes.

Delay action until she gains more familiarity with the unit's dynamics. Delaying action can compromise patient safety and staff well-being. Immediate concerns about staffing should be addressed promptly to prevent potential negative outcomes.

Announce that staff must take turns volunteering for the night shift. This solution may not be fair or effective and could lead to staff dissatisfaction and burnout. It does not address the root cause of the staffing issue and may create additional conflicts within the team.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Yoder-Wise, P. S. (2019). Leading and Managing in Nursing (7th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Thiamine. Thiamine (vitamin B1) deficiency is most frequently observed in individuals with long-term alcohol dependency. Chronic alcoholism interferes with the absorption, storage, and utilization of thiamine, leading to deficiencies. This can result in serious conditions such as Wernicke-Korsakoff syndrome, which is characterized by neurological symptoms including confusion, ataxia, and memory problems. Thiamine is essential for energy metabolism and proper nerve function, making its deficiency particularly detrimental to health.

Think of thiamine as a key ingredient needed for a car’s engine to run smoothly. Without it, the engine (body) starts to malfunction, leading to serious problems. Similarly, without enough thiamine, the body's essential functions begin to break down, especially in the nervous system.

Proper nutritional assessment and supplementation are crucial in managing patients with chronic alcoholism. Identifying and treating thiamine deficiency early can prevent severe complications and improve patient outcomes. Healthcare providers should be vigilant in assessing the nutritional status of these patients and providing appropriate interventions.

 

✘Incorrect answer options:

Riboflavin. While riboflavin (vitamin B2) deficiency can occur, it is less commonly associated with chronic alcoholism compared to thiamine deficiency.

Pyridoxine. Pyridoxine (vitamin B6) deficiency can also be seen in alcoholics, but it is not as prevalent or as critical as thiamine deficiency in this context.

Pantothenic acid. Deficiency in pantothenic acid (vitamin B5) is rare and not typically associated with chronic alcoholism.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Sufficient oxygen supply. According to Maslow's hierarchy of needs, physiological needs are the most fundamental and must be satisfied first before higher-level needs can be addressed. Within the physiological level, the need for sufficient oxygen supply is the highest priority. Oxygen is essential for cellular metabolism and overall body function. Without adequate oxygen, an individual cannot survive, making it the most critical need among all physiological requirements.

Think of physiological needs as the foundation of a building. Oxygen is like the solid ground that supports everything else. Without it, the entire structure (the body) cannot stand. Once a solid ground (oxygen supply) is ensured, other layers like food, water, and shelter can be built upon it.

Maslow's hierarchy of needs is a psychological theory that prioritizes human needs from the most basic to the most advanced. It starts with physiological needs (oxygen, food, water, and shelter), followed by safety, love and belonging, esteem, and finally self-actualization. Understanding this hierarchy helps nurses prioritize patient care effectively, ensuring that the most critical needs are addressed first.

 

✘Incorrect answer options:

Experiencing love and belonging. This option is incorrect because love and belonging are part of the third level of Maslow's hierarchy, which addresses social needs. These needs are important but only after physiological and safety needs are met.

The need for regular elimination. While elimination is an essential physiological need, it is not as immediately critical as the need for oxygen. The body can tolerate delays in elimination longer than a lack of oxygen.

Adequate nutrition. Adequate nutrition is also a vital physiological need, but it is secondary to the need for oxygen. The body can survive longer without food than without oxygen.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–396.

EXPLANATION

 

✔Correct answer:

All of the mentioned aspects.  A comprehensive respiratory assessment involves checking the rate, rhythm, and symmetry of chest movements. Each of these aspects provides critical information about the patient's respiratory function:

• Rate of breathing: This refers to the number of breaths taken per minute and helps determine if the patient is breathing at a normal, rapid, or slow rate.
• Rhythm of breathing: This indicates whether the breathing pattern is regular or irregular, providing insight into the patient's respiratory control and any potential issues with respiratory mechanics.
• Symmetry of chest movements: Observing whether both sides of the chest rise and fall equally ensures there is no obstruction, collapsed lung, or other issues affecting one side of the respiratory system.

Think of evaluating a car’s engine performance. You wouldn’t just check the speed (rate) at which the engine runs; you’d also listen for consistent sounds (rhythm) and ensure all parts are moving in sync (symmetry). Similarly, a thorough respiratory assessment involves looking at multiple aspects to get a complete picture.

A comprehensive assessment of respiratory function is crucial in identifying any abnormalities or issues that may require intervention. By evaluating the rate, rhythm, and symmetry of respirations, nurses can detect early signs of respiratory distress, infections, or other conditions that may impact breathing.

 

✘Incorrect answer options:

The rate of breathing. While important, assessing only the rate does not provide a full picture of respiratory function.

The rhythm of breathing. While rhythm is crucial, it must be assessed alongside other factors for a comprehensive evaluation.

The symmetry of chest movements. Symmetry is essential, but evaluating it alone without considering rate and rhythm would be incomplete.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

An 88-year-old incontinent patient with gastric cancer who is bedridden at home. This patient is at the highest risk for developing pressure ulcers due to multiple risk factors. Being bedridden significantly increases the risk as it leads to prolonged pressure on certain areas of the body, particularly bony prominences. Incontinence adds to the risk because moisture from urine or feces can break down the skin, making it more susceptible to ulcers. Additionally, advanced age and having a serious illness like gastric cancer further compromise the skin's integrity and healing capacity.

Imagine a piece of cloth that is constantly pressed against a rough surface and exposed to moisture. Over time, it starts to wear and tear much faster than if it were dry and free from pressure. Similarly, the skin of a bedridden, incontinent patient is much more prone to developing pressure ulcers.

Pressure ulcers, also known as bedsores, develop due to sustained pressure, friction, and shear, particularly in patients who are immobile. Key risk factors include immobility, incontinence, poor nutrition, advanced age, and serious medical conditions. Comprehensive risk assessment tools like the Braden Scale are used in clinical practice to evaluate patients' risk levels and implement preventive measures.

 

✘Incorrect answer options:

An alert patient with chronic arthritis being treated with steroids and aspirin. While steroids can thin the skin and aspirin can affect clotting, this patient is alert and likely more mobile than the bedridden patient, reducing their overall risk for pressure ulcers.

An apathetic 63-year-old with COPD who is receiving oxygen therapy via a nasal cannula. This patient might have compromised oxygenation, which can affect skin health, but unless they are also immobile or incontinent, their risk for pressure ulcers is lower compared to a bedridden patient.

A confused 78-year-old with congestive heart failure who needs help to get out of bed. This patient has several risk factors, including confusion and mobility issues, but they are not completely bedridden, and incontinence is not mentioned, making their risk lower than the bedridden patient.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

The nurse administers penicillin to a patient despite knowing the patient's documented allergy to the drug, causing the patient to suffer an allergic reaction and cerebral damage due to anoxia. This scenario constitutes nursing malpractice. Malpractice involves a failure to meet the standard of care, resulting in harm to the patient. Administering penicillin to a patient with a known allergy is a clear breach of the duty of care. The nurse had a responsibility to review the patient's allergies and avoid giving a medication that could cause harm. The resulting allergic reaction and cerebral damage due to anoxia demonstrate significant harm caused by this breach of duty.

Imagine a mechanic who knows that a car has a brake issue but chooses to ignore it and allows the car to be driven, leading to an accident. The mechanic's negligence in addressing the known issue is similar to the nurse's negligence in ignoring a known allergy, leading to serious harm.

Nursing malpractice occurs when a nurse fails to follow established standards of care, resulting in patient injury or harm. This scenario highlights the importance of thorough patient assessments and adherence to safety protocols, particularly regarding allergies and medication administration.

 

✘Incorrect answer options:

The nurse uses a hot water bottle or a heating pad on a patient with abdominal cramps. While using heat therapy requires caution, this action alone does not necessarily constitute malpractice unless it directly causes harm due to improper use.

The nurse helps a patient out of bed, keeping the bed locked in position; however, the patient slips and fractures his right humerus. This scenario could be considered an accident. Without evidence of negligence or failure to meet the standard of care, it is not necessarily malpractice.

The nurse gives a patient the incorrect medication, after which the patient vomits; the incident is documented and reported to both the physician and the nursing supervisor. Although giving the incorrect medication is a serious error, proper documentation and reporting, along with no significant harm beyond vomiting, may not rise to the level of malpractice. It indicates a medication error rather than a willful or grossly negligent act.

 

References

• Guido, G. W. (2014). Legal and Ethical Issues in Nursing (6th ed.). Pearson.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Supine. The most suitable position for an abdominal inspection is the supine position. This position involves the patient lying flat on their back with arms at their sides. It allows for optimal visualization and access to the entire abdomen, making it easier to inspect for distention, symmetry, skin changes, and other abnormalities. The supine position also facilitates accurate palpation and auscultation by providing a flat surface and reducing muscle tension in the abdominal wall.

Imagine trying to examine the contents of a suitcase. It’s easiest to see everything clearly when the suitcase is lying flat and open on a table, rather than being propped up at an angle or on its side. Similarly, the supine position provides a flat and even surface for the most thorough abdominal examination.

Proper patient positioning is crucial for accurate and thorough physical examinations. The supine position minimizes abdominal muscle tension and provides a clear view and access to all quadrants of the abdomen, facilitating comprehensive inspection, palpation, and auscultation.

 

✘Incorrect answer options:

Prone. The prone position, where the patient lies on their stomach, is not suitable for abdominal inspection as it obscures the abdomen and makes examination difficult.

Trendelenburg. The Trendelenburg position involves the patient lying supine with the head lower than the feet. This position is not optimal for abdominal inspection as it can shift abdominal contents and obscure findings.

Side-lying. The side-lying position also restricts access to the entire abdomen and makes it challenging to perform a thorough and accurate inspection.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

A patient unable to care for themselves at home. A patient who is unable to care for themselves at home does not typically fall under impaired awareness. Impaired awareness generally refers to patients who have a reduced ability to perceive, understand, or respond to their environment due to altered mental status, confusion, or consciousness levels. While a patient unable to care for themselves may have physical limitations or lack the skills needed for self-care, this situation does not necessarily imply impaired awareness.

Think of impaired awareness as someone wearing foggy glasses—they can't see clearly and may not understand what’s happening around them. In contrast, someone who can't drive due to a broken leg knows they can't drive but still understands their surroundings perfectly.

Recognizing impaired awareness is crucial for ensuring patient safety and providing appropriate care. Patients with altered mental status, confusion, or consciousness issues require specific interventions to prevent harm and ensure they receive the necessary support and supervision.

 

✘Incorrect answer options:

A semiconscious or overly fatigued patient. These patients may have impaired awareness due to their reduced level of consciousness.

A disoriented or confused patient. These patients have impaired awareness as they may not fully understand their environment or situation.

A patient showing symptoms of drug or alcohol withdrawal. Withdrawal can cause altered mental status, leading to impaired awareness.

 

References

• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing (10th ed.). Elsevier.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.