(Test Bank) Psychiatric & Mental Health

Lacharity, 3

Nursing

Test Bank

3rd Edition

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Test Bank for Psychiatric & Mental Health, The downloadable file consists of 197 pages, and the total size of the file is 0.94 MB. Purchase now only for highly discounted price.

Author(s): Lacharity

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Lacharity Psychiatric & Mental Health Chapters 1 -21 (3rd Edition) Test Bank 1. You are the charge nurs e. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator t o provide in -service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client. 1. Ans: 4 As charge nurse, you must assess the p erformance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013 -11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Healt h Sciences. Kindle Edition. 2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addic tion?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?" 2. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. F ocus: Prioritization 3. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013 -11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition. 3. A client with diabetic neuropathy reports a burning, electrical -type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti -inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan) 3. Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger op ioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant nedication. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013 -11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition. 4. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A clie nt with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia 4. Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization LaCharity, Linda A.; K umagai, Candice K.; Bartz, Barbara (2013 -11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition. 5. As the charge nurse, you are reviewing the charts of clients who were a ssigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in -service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in chartin g. 5. Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time -cons uming approach. Making a note and watching do not help the nurse to correct the immediate problem. In -service training might be considered if the problem persists. Focus: Supervision, delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (20 13-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition. 6. Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automob ile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis ... 7. In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach i s needed. 3. The client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed. ... 8. Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp ch est pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an ele vated blood pressure ... 9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free. 3. Titrate downward to prevent toxicity. 4. Titrate to a dosage that is adequate to meet the client's subjective needs. ... 10. For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will fu nction with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS) ... 11. A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclo benzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? 1. Call the physician to obtain an order for naloxone (Narcan). 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20/min. 4. Double -check the drug order to see what the client should have received. ... 12. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Elderly client with chronic pain who has a hip fracture 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Child with an arm fracture and cystic fibrosis ... 13. A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem. ... 14. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps ... 15. In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress ... 16. The physician has ordered a placebo for a client with chronic pa in. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? 1. Prepare the medication and hand it to the physician. 2. Check the hospital policy regarding the use of a placebo . 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice. ... 17. For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonve rbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. 4. Give the maximum PRN dose within the minimum ti me frame for relief. ... 18. You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient -controlled analgesia (PCA) pump frequently with good relief and occasionally asks for b olus doses. 3. Middle -aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long -term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. _____, _____, _____, _____, _____ ... 19. On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? 1. Deliver the bolus dose per standing order. 2. Contact the physician to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for locati on, quality, and intensity. ... 20. The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1. Calling the physician and reporting the situation using the S BAR (situation, background, assessment, recommendation) format 2. Giving the ordered dose of Narcan and evaluating the response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered ... 21. What is the best way to schedule medication for a client with constant pain? 1. PRN at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around the clock ... 22. Which clients can be appropriately assigned to an LPN/LV N who will function under the supervision of an RN or team leader? Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Clie nt who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs sc heduled pain medications and heat applications ... 23. You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment finding s include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the follo wing report information in the correct order according to the SBAR format. 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and ten der to touch with hypoactive bowel sounds." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dos e of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" 5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal p ain."_____, _____, _____, _____, _____ ... 24. Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be dis charged with a new surgically - implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication ... 25. A client's family member says to you, "He needs more pain med icine. He is still having a lot of pain." What is your best response? 1. "The physician ordered the medicine to be given every 4 hours." 2. "If the medication is given too frequently, he could experience ill effects." 3. "Please tell him that I will be rig ht there to check on him." 4. "Let's wait about 30 to 40 minutes. If there is no relief, I'll call the physician." ... 26. Pain disorder and depression have been diagnosed for a client. Hereports chronic low back pain and states, "None of these doctors hasdone anything to help." Which client statement concerns you the most? 1. "I twisted my back last night, and now the pai n is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything forme." ... 27. A client has severe pain and bladder distention related to urinaryretention and possible obstruction. An experienced UAP states that shereceived training in Foley catheter insertion at a previous job. What taskcan be delegated to this UAP? 1. Assessing the bladder dis tention and the pain associated with urinaryretention 2. Inserting the Foley catheter, once you ascertain that she knows steriletechnique 3. Evaluating the relief of pain and bladder distention after the catheter isinserted60 4. Measuring the urine output after the catheter is inserted and obtaininga urine specimen ... 28. You are caring for a young man with a history of substance abuse whohad exploratory abdominal surgery 4 days ago for a knife wound. There isan order to discontinue the PCA -delivered morph ine and to start oralpain medication. The client begs, "Please don't stop the morphine. Mypain is really a lot worse today than it was yesterday." What is the bestresponse? 1. "Let me stop the pump and we can try oral pain medication to see if itrelieves t he pain." 2. "I realize that you are scared of the pain, but we must try to wean youoff the pump." 3. "Show me where your pain is and describe how it feels compared toyesterday." 4. "Let me take your vital signs, and then I will call the physician andexpla in your concerns." ... 29. You are caring for a young client with diabetes who has sustainedinjuries when she tried to commit suicide by crashing her car. Her bloodglucose level is 650 mg/dL, but she refuses insulin; however, she wantsthe pain medication. What is the best action? 1. Notify the charge nurse and obtain an order for a transfer to intensivecare. 2. Explain that insulin is a priority and inform the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.Answer Key for this chapter begins onp. 167.61 ... A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no eviden ce of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? A. Present reality: "Sir, you have been seen many times in this clinic and had man y diagnostic tests. The results have always been negative." B. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." C. Set boundaries: "Sir, I will take your VS, b ut then I am going to call your case manager so that you can discuss the scheduled appointment." D. Respect the patients wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you." C. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment." You are caring for a patient in whom a conversation disorder was recently diagnosed. She is experiencing a sudde n loss of vision after witnessing a violent fight between her husband and adult -age son. What is the priority therapeutic approach to use with this patient? A. Reassure her that her blindness is temporary and will resolve with time B. Gently point out that she seems to be able to see well enough to function independently C. Encourage expression of feelings and link emotional trauma to the blindness D. Teach ways to cope with blindness, such as methodically arranging personal items D. Teach ways to cope with blindness, such as methodically arranging personal items As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? A. Male LVN assigned to a male patient with chronic dep ression and excessive rumination B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa C. Female RN assigned to a newly admitted female patient who has command hallucination sand delusions of persecution D. Older femal e RN with medical -surgical experience assigned to a male patient with Alzheimer disease B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? A. Jane, come and sit in my house until this is over with B. Jane, calm down and let the fireman do his job C. Jane, look at me and hold my hand D. Jane, t ell me why you are struggling so hard C. Jane, look at me and hold my hand There is a patient on the medical -surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you ha ndle the assignment? A. Rotate the assignment schedule so that no one has to care for him more than once or twice a week B. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the p atient C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions D. Assign yourself as primary caregiver sot hat you can role -model how patients should be treated C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions A patient diagnosed with paranoid schizophrenia tells you that "Dr. Smith has killed several other patients and now he is trying to kill me." What is the b est response? A. I have worked here a long time. No one has died. You are safe here B. What has Dr. Smith done to make you think he would like to kill you? C. All of the staff, including Dr. Smith, are here to ensure your safety. D. Whenever you are concer ned or nervous, talk to me or any of the nurses D. Whenever you are concerned or nervous, talk to me or any of the nurses A nursing student reports to you that he has observed several types of behavior among the patients. Which patient needs priority asses sment? A. A patient who is having command hallucinations B. A patient who is demonstrating clang associations C. A patient who is verbalizing ideas of reference D. A patient who is using neologisms A. A patient who is having command hallucinations Mr. J ha s a panic disorder and it appears that he is having some problems controlling his anxiety. Which symptoms concern you the most? A. His HR is increased and reports chest tightness B. He demonstrates tachypnea and carpopedal spasms C. He is pacing and poundi ng his fists together D. He is muttering to himself and is easily startled C. He is pacing and pounding his fists together You are interviewing a patient with suicidal ideations and a history of major depression. Which comment concerns you the most? A. I h ave had problems with depression most of my adult life B. My father and my brother both committed suicide C. My wife is having health problems and she relies on me D. I am afraid to kill myself, and I wished I had more courage B. My father and my brother both committed suicide A patient comes into the walk -in clinic and tells you that he wants to be admitted to alcohol rehabilitation program. Which question is the most important to ask? A. What made you decide to enter a program at this time? B. How much alcohol do you usually consume in a day? C. When was the last time your had a drink? D. Have you been in a rehabilitation program before? C. When was the last time your had a drink? A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task should be delegated to the mental health assistant? A. Wiping the patient's body with cool moist towels B. Monitoring VS every 15 minutes C. Attaching ECG monitor D. Assigns the RN to transfer the patient to the ICU A. Wiping the patient's body with cool moist towels Which patient should be assigned to a newly -graduated nurse who has just started on the unit? A. Patient who is frequently admitted for borderline perso nality disorder and suicidal gesture B. Patient admitted yesterday for disorganized schizophrenia and psychosis C. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium D. Patient newly diagnosed with major depress ion and rumination about loss and suicide D. Patient newly diagnosed with major depression and rumination about loss and suicide Which task can be assigned to a medical -surgical UAP who has been floated to the acute psychiatric unit? A. Performing one -to-one observation of a patient who is suicidal B. Assisting the OT to conduct a craft class C. Accompanying an elderly patient who wanders on a walk outside D. Assisting the medication nurse who is having problems with a patient C. Accompanying an elderly pat ient who wanders on a walk outside The team has to apply restraints to a combative patient in order to prevent harm to others or to self. Which action requires your intervention? A. Mental health assistant uses a quick -release knot B. MD secures the restra int to the side rail C. RN check the pulses distal to restraint D. LPN explains to the patient why he being restrained B. MD secures the restraint to the side rail A well -known celebrity is admitted to your unit. Several RNs from other units drop by and ex press an interest in seeing the patient. What is the best response? A. Please be discreet and do not interrupt the work flow B. How did you find out that the patient was admitted to this unit? C. Please wait. I need to call the nursing supervisor about thi s request D I'm sorry; the patient has asked that only family be allowed to visit B. How did you find out that the patient was admitted to this unit? An LPN complains to you that she is always assigned to the same patient with chronic depression. What shou ld you do? A. Look at the assignment sheet and see if there is any way to switch assignments with another LPN B. Tell her to care for the patient today, but that you will remember the request for future assignments C. Remind her that continuity of care and patient -centered care are the primary goals D. Explain that patients with chronic conditions are more likely to fall under the LPN scope of practice B. Tell her to care for the patient today, but that you will remember the request for future assignments The ED is calling to report on a patient who will be admitted to your acute psychiatric unit. HE has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions and minor lacerations. What is the priority question that you should ask? A. When will the patient be transferred? B. Will a police officer be with him while he is on the unit? C. Why isn't the patient being admitted to the trauma unit? D. What is the patient's current mood and behavior ? D. What is the patient's current mood and behavior? A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following step s in the correct sequence so that you can teach the nursing student how ti prevent medication errors. A. Advise the pharmacy of any corrections as appropriate B. Recognize the "look -alike, sound -alike" drugs increase the chances of error C. Consult a medic ation book to verify the purpose of the drugs and generic and brand names D. Check the original medication order to verify what was prescribed E. Write an incident report, as appropriate, if you believe that a system error is occurring F. Call the MD for c larification of the order as appropriate B. Recognize the "look -alike, sound -alike" drugs increase the chances of error D. Check the original medication order to verify what was prescribed C. Consult a medication book to verify the purpose of the drugs and generic and brand names F. Call the MD for clarification of the order as appropriate A. Advise the pharmacy of any corrections as appropriate E. Write an incident report, as appropriate, if you believe that a system error is occurring A patient is display ing muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He is being prescribed haloperidol. What is the priority action? A. Encourage him to look at you and stay with him until the spasms pass B. Place the patient on asp iration precautions until the spasms subside C. Obtain an order for IM or IV diphenhydramine D. Obtain an order for and administer an anti seizure medication C. Obtain an order for IM or IV diphenhydramine Several patients are taking antipsychotic medicati ons and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions. A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity , and dysphagia B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000 C. A patient who is taking loxapine and has a protruding tongue wi th lip smacking and spastic facial distortions A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and f lulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000 B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity You are reviewing the pr inciple of "least restrictive" intervention with the staff. Place the following intervention in the correct ascending order from the least restrictive to the most restrictive. A. Escort the patient to a quite room for a time out B. Restrain the patient's a rms and legs with soft cloth restraints C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard E. Restrain the patient's upper extremities with wris t restraints F. Place the patient in an isolation room with a mental health assistant observing C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtya rd A. Escort the patient to a quite room for a time out F. Place the patient in an isolation room with a mental health assistant observing E. Restrain the patient's upper extremities with wrist restraints B. Restrain the patient's arms and legs with soft clothrestraints Which behavior would be the most problematic and require vigilance to prevent danger to self or others? A. Avolition B. Echolalia C. Motor agitation D. Stupor C. Motor agitation A patient co mes in to the clinic with nausea, constipation, and "excruciating stomach pain." Over a period of several years, this patient has come in two or three times a month with the same report, but multiple diagnostic tests have consistently yielded negative resu lts for physical disorders. What is the priority nursing intervention for this patient? A. Advocate for the patient to have a psychiatric consultation B. Ensure that the patient sees the same health care provider for continuity C. Perform a physical assess ment to identify any physical abnormalities D. Assess for concurrent symptoms of depression or anxiety C. Perform a physical assessment to identify any physical abnormalities An elderly man was admitted for palliative care of terminal pancreatic cancer. Th e wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis if this sentin el event? (Select all that apply) A. The wife and all immediate family members B. Only the MD who discharged the patient C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient E. Only the R N who discharged the patient F. Any MD who has involved int eh care of this patient C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient F. Any MD who has involved int eh care of this pat ient An adolescent girl is admitted to your medical -surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months At this time, what is the primary collaborative goal for the treatment of Ms. C? A. Assist her to increase feelings of control B. Decrease power struggles over eating C. Resolve dysfunctional family roles D. Restore normal nutrition and weight D. Restore normal nutrition and weight An adolescent girl is admitted to your medical -surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months For Ms. C, which route for delivery of nutrition and fluids will the health care team try first? A. NG B. PO C. IV D. Hypodermoclysis B. PO An adolescent girl is admitted to your medical -surgical unit for diag nostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months In caring for this patient with anorexia nervosa, which tas k can be delegated to the UAP? A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals B. Observing for the reporting ritualistic behaviors related to food C. Obtaining special food for the patient when she requests it D. Weighting the pati ent daily and reinforcing that she is underweight A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals An adolescent girl is admitted to your medical -surgical unit for diagnostic evaluation and nutritional support related to anorexia ner vosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months You find Ms. C in her room jogging in place and doing jumping jacks "for about the last 20 minutes." What is the best response to give at this time? A. You can of for a few more minutes, but then you will tell me why your are exercising B. If you continue to exercise like this, you are just going to have to eat more at mealtimes C. Stop jogging right now. This is unacceptable behavior and you will lose all privileges D. We have talked about exercise, any you agreed to reach your target weight goal first D. We have talked about exercise, any you agreed to reach your target weight goal first An adolescent girl is admitted to your medical -surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her p otassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months Ms. C's self -esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize an appropriate d iet and exercise plan. What is the priority nursing diagnosis? A. Imbalanced Nutrition: Less that Body Requirements B. Disturbed Body Image C. Risk for Situational Low Self -Esteem D. Ineffective Health Maintenance B. Disturbed Body Image In caring for a 3 -year-old with pain, which assessment question would be the most useful? 1. "Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. "If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. "The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. "One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt? " Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other t ools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization Which pediatric pain patient should be assigned to a newly -graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient - controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end -of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chroni c pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful Ans: 2 The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psych ological issues related to pain management. Focus: Delegation You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory re sult causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L 2. A nosebleed with a platelet count of 100,000/mm3 3. Fever with an absolute neutrophil count of 450/mm3 4. Fatigue with a hemoglobin level of 8 g/d L Ans: 3 National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the pr iority. A potassium level of 3.3 mEq/L is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontan eous hemorrhage is not expected until the platelet count drops below 20,000 mm3. Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. Focus: Prioritization . A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the chil d that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mothe r that the behavior could be a normal expression of anger. Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal w ith the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft die t Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if t he child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation As the pediatric unit charge nurse, you are making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN/LVN? 1. 1-year-old with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant 2. 2-year-old with Wiskott -Aldrich syndrome who has orders for a platelet transfusion 3. 3-year-old who has chronic graft -versus -host disease and is incontinent of loose stools 4. 6-year-old who received chemotherapy a week ago and is admitted with increas ing lethargy and a temperature of 101° F (38.3° C) Ans: 3 LPN/LVN scope of practice includes care of patients with chronic and stable health problems, such as the patient with chronic graft -versus -host disease. Chemotherapy medications are considered high -alert medications and should be given by RNs who have received additional education in chemotherapy administration. Platelets and other blood products should be given by RNs. The 6 -year-old patient has a history and clinical manifestations consistent with neutropenia and sepsis and should be assessed by an RN as quickly as possible. Focus: Assignment You are the pediatric unit charge nurse working with a new RN. Which action by the new RN requires the most immediate action on your part? 1. Placing a child w ho has chemotherapy -induced neutropenia into a negative -pressure room 2. Wearing goggles to change the linens of a patient who has diarrhea caused by Clostridium difficile 3. Instructing UAPs to use an N95 respirator mask when caring for a child who has pe rtussis 4. Admitting a new patient with respiratory syncytial virus (RSV) infection to a room with another child who has RSV 1. child in a negative -airflow room will increase the likelihood of infection for this patient. Although private rooms are preferre d for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients who are infected with the same microorganism. The use of an N95 respirator is not necessary for pertussis, and goggles are not needed for changing the linens of patients infected with C. difficile; however, these precautions do not increase risk to the patients. Focus: Prioritization You are preparing to care for a 6 -year-old who has just undergone allogeneic stem cell transplant ation and will need protective environmental isolation. Which nursing tasks will you delegate to the UAP? (Select all that apply.) 1. Stocking the patient's room with the needed personal protective equipment items 2. Teaching the patient to perform thoroug h hand washing after using the bathroom 3. Reminding visitors to wear a respirator mask, gloves, and gown 4. Posting the precautions for protective isolation on the door of the patient's room 5. Talking to the family members about the reasons for the isola tion Ans: 1, 3, 4 Because all patient care staff members should be familiar with the various types of isolation, a UAP will be able to stock the room and post the precautions on the patient's door. Reminding visitors about previously taught information is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Patient teaching and discussion of the reasons for the protective isolation fall within the RN - level scope of practice. Focus: Delegation You are a public schoo l nurse. Which action will you take to have the most impact on the incidence of infectious diseases in the school? 1. Make soap and water readily available in the classrooms. 2. Ensure that students are immunized according to national recommendations. 3. Provide written information about infection control to all parents. 4. Teach students how to cover their mouths when they cough or sneeze. Ans: 2 The incidence of once -common infectious diseases such as measles, chickenpox, and mumps has been most effective ly reduced by the immunization of all school -age children. The other actions are also helpful but will not have as great an impact as immunization. Focus: Prioritization While working in the pediatric clinic, you receive a telephone call from the parent of a 13 -year-old who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (varicella). Which action will you anticipate taking next? 1. Administer v aricella -zoster immune globulin to the patient. 2. Teach the parent about the correct use of acyclovir (Zovirax). 3. Educate the parent about contact and airborne precautions. 4. Prepare to admit the patient to a private room in the hospital. Ans: 1 The ad ministration of varicella -zoster immune globulin can prevent the development of varicella in immunosuppressed patients and will typically be prescribed. Acyclovir therapy and hospitalization may be required if the child develops a varicella -zoster virus in fection. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. Focus: Prioritization You are the charge nurse on the pediatric unit when a pediatrician calls wanting to ad mit a child with rubeola (measles). Which factor is of most concern in determining whether to admit the child to your unit? 1. The unit is staffed with fewer RNs than usual. 2. No negative -airflow rooms are available. 3. The infection control nurse liaison is not present today. 4. There are several children receiving chemotherapy. Ans: 2 Because patients with rubeola require implementation of airborne precautions, which include placement in a negative -airflow room, this child cannot be admitted to the pedia tric unit. The other circumstances may require actions such as staff reassignments but would not prevent the admission of a patient with rubeola. Focus: Prioritization A 16-year-old with cystic fibrosis is admitted with increased shortness of breath and po ssible pneumonia. Which nursing activity is most important to include in the patient's care? 1. Allowing the patient to decide whether she needs aerosolized medications 2. Placing the patient in a private room to decrease the risk of further infection 3. Scheduling postural drainage and chest physiotherapy (CPT) every 4 hours 4. Planning activities to allow for at least 8 hours of uninterrupted sleep Ans: 3 National guidelines indicate that airway clearance techniques are critical for patients with cystic fibrosis; CPT should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desira ble for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep. Focus: Prioritization You have obtained this assessment information about a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow -up? 1. Frequent swallowing 2. Hypotonic bowel sounds 3. Reports of a sore throat 4. Heart rate of 112 beats/min Ans: 1 Frequent swallowing after tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are expected in a 3 -year-old after surgery. Focus: Prioritization You are providing nursi ng care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is most important to report to the health care provider? 1. Apical pulse rate of 156 beat s/min 2. Crackles audible in both lungs 3. Tracheal deviation to the right 4. Oxygen saturation of 93% Ans: 3 Tracheal deviation suggests tension pneumothorax, a possible complication of positive -pressure ventilation. The nurse will need to communicate rap idly with the health care provider and assist with actions such as chest tube insertion. The heart rate, crackles, and oxygen saturation will be reported to the health care provider, but are expected in RDS and do not require immediate intervention. Focus: Prioritization You are assisting with the delivery of a 31 -week gestational age premature newborn who requires intubation for RDS. Which medication will you anticipate will be needed first for this infant? 1. Theophylline (Theolair, Theochron) 2. Surfacta nt (Exosurf) 3. Dexamethasone (Decadron) 4. Albuterol (Proventil) Ans: 2 Research indicates that the administration of synthetic surfactant improves respiratory status and decreases the incidence of pneumothorax in premature infants with RDS. The other med ications may be used if respiratory distress persists, but the first medication administered will be the surfactant. Focus: Prioritization You obtain this information when assessing a 3 -year-old with uncorrected tetralogy of Fallot who is crying. Which fin ding requires immediate action? 1. The apical pulse rate is 118 beats/min. 2. A loud systolic murmur is heard in the pulmonic area. 3. There is marked clubbing of all of the child's nail beds. 4. The lips and oral mucosa are dusky in color. Ans: 4 Circumor al cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee -chest position, administer oxygen, and take steps to calm the child. The other assess ment data are expected in a child with congenital heart defects such as tetralogy of Fallot. Focus: Prioritization After receiving the change -of-shift report, which patient should you assess first? 1. 18-month -old with coarctation of the aorta who has decr eased pedal pulses 2. 3-year-old with rheumatic fever who reports severe knee pain 3. 5-year-old with endocarditis who has crackles audible throughout both lungs 4. 8-year-old with Kawasaki disease who has a temperature of 102.2° F (39° C) Ans: 3 Crackles throughout both lungs indicate that the child has severe left ventricular failure as a complication of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administrati on of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life -threatening complications of their medical diagnoses. Focus: Prioritization As the pediatric unit charge nurse, you a re working with a newly -graduated RN who has been on orientation in the unit for 2 months. Which patient should you assign to the new RN? 1. 2-year-old with a ventricular septal defect for whom digoxin (Lanoxin) 90 mcg by mouth has been prescribed 2. 4-year-old who had a pulmonary artery banding and has just been transferred in from the intensive care unit 3. 9-year-old with mitral valve endocarditis whose parents need teaching about IV antibiotic administration 4. 16-year-old with a heart transplant who wa s admitted with a low -grade fever and tachycardia Ans: 1 This patient requires the least complex assessments and interventions of the four patients. Safe administration of oral medications such as digoxin would have been included in the orientation of the new RN graduate. The conditions of the other patients are more complex, and they require assessments and/or interventions (such as teaching) that should be carried out by an RN with more experience. Focus: Assignment You are obtaining the history and physi cal information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information about this patient will concern you most? 1. The child attends a day -care center 5 days a week. 2. The child's fingers have areas of peeling skin. 3. The child is very irritable and cries frequently. 4. The child has not received any immunizations. Ans: 4 Children who receive aspirin therapy are at risk for the development of Reye syndrome if they contract viral illnesses such as varicella or influenza, so the lack of immunization is the greatest concern for this child. Peeling skin on the fingers and toes and irritability are consistent with Kawasaki disease, but do not require any change in therapy. Since Kawasaki disease is not a communicabl e disease, day care need not be avoided. Focus: Prioritization You are working with an LPN/LVN who is caring for a 10 -year-old who has severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires that you intervene immediately? 1. Suggesting genetic counseling to the patient 2. Positioning cold packs on the patient's knees 3. Placing a "No Visitors" sign on the patient's door 4. Checking the patient's temperature every 2 hours Ans: 2 The joint pain that occ urs in sickle cell crisis is caused by obstruction of blood flow by the red blood cells. Cold packs will further decrease blood flow to the patient's knees and increase sickling. The appropriate therapy for this patient is application of moist heat to the joints to cause vasodilation and improve circulation. Genetic counseling may be provided to patients with sickle cell disease but is not appropriate to suggest to a 10 -year-old. Although infection control is important in preventing and treating sickle cell crisis, there is no need to restrict all visitors or to check the patient's temperature every 2 hours. Focus: Prioritization You have just received a change -of-shift report about these pediatric patients. Which patient will you assess first? 1. 1-year-old with hemophilia B who was admitted because of decreased responsiveness 2. 3-year-old with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled 3. 7-year-old with acute lymphocytic leukemia who has chemotherapy -induced thrombocytopenia 4. 16-year-old with sickle cell disease who reports acute right lower quadrant abdominal pain Ans: 1 Because decreased responsiveness in a 1 -year-old with a clotting disorder may indicate intracerebral bleeding, this patient should be assessed immediately. The other patients also require assessments or interventions but are not at immediate risk for life -threatening or disabling complications. Focus: Prioritization You are reviewing the complete blood count for a 3 -year-old who has been diagnosed with idiop athic thrombocytopenic purpura. Which information should you report immediately to the health care provider? 1. Increased eosinophil level 2. Hemoglobin level of 6.1 g/dL 3. Platelet count of 40,000/mm3 4. Elevated reticulocyte count Ans: 2 The low hemoglo bin level suggests that the child may have active bleeding, and rapid actions such as diagnostic testing and transfusions are indicated. The other laboratory data are expected in a child with idiopathic thrombocytopenic purpura. Focus: Prioritization A 4-year-old with acute lymphocytic leukemia has these medications ordered. Which one is most important to double -check with another licensed nurse? 1. Prednisone (Deltasone) 1 mg by mouth (PO) 2. Amoxicillin (Amoxil) 250 mg PO 3. Methotrexate (Rheumatrex) 10 m g PO 4. Filgrastim (Neupogen) 5 mcg subcutaneously Ans: 3 Methotrexate is a high -alert drug, and extra precautions, such as double -checking with another nurse, should be taken when administering this medication. Although many pediatric units have a policy requiring that all medication administration to children be double -checked, the other medications listed are not on the high -alert list published by the Institute for Safe Medication Practices. Focus: Prioritization You are the charge nurse on the pediatric neurologic unit when the health care provider calls with new medication prescriptions for several patients with seizure disorders. Which prescription is most important to verify with the provider? 1. Ibuprofen (Mot rin) 10 mg/kg for a 2 -year-old having a febrile seizure 2. Phenytoin (Dilantin) 300 mg/day for a 6 -year-old with tonic -clonic seizures 3. Valproic acid (Depakote) 15 mg/kg/day for an 11 -year-old with absence seizures 4. Carbamazepine (Tegretol) 100 mg ever y 8 hours for a 70 -kg 17 -year-old with complex seizures Ans: 2 National guidelines indicate that medication dosing for pediatric patients should be based on the child's weight. The weight for the 6 -year-old is not provided. For phenytoin, the dose for chil dren is prescribed as 5 mg/kg in 2 or 3 divided doses; 300 mg is a typical maintenance dose for an adult, but would be an unusual dose for a 6 -year-old. All telephone orders should be verified; however, the dosages for the other three prescriptions are app ropriately based on the child's weight. Focus: Prioritization You are caring for a 3 -year-old who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is most i mportant to communicate to the surgeon? 1. The child is crying and says, "It hurts!" 2. The right pupil is 1 mm larger than the left pupil. 3. The cardiac monitor shows a heart rate of 130 beats/min. 4. The head dressing has a 2 -cm area of bloody drainage. Ans: 2 Pupil dilation may indicate increased intracranial pressure and should be reported immediately to the surgeon. The other data are not unusual in a 3 -year-old after surgery, although they indicate the need for ongoing assessments or interventions. F ocus: Prioritization You are caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern? 1. Bulging of the sac when the infant cries 2. Oozing of stool from the anal sphincter 3. Flaccid paralysis of both legs 4. Temperature of 101.8° F (38.8° C) Ans: 4 The elevated temperature indicates possible infection and should be reported immediately to the physician so that treatment can be started. The other data are typical in an infant with this defect. Focus: Prioritization An excited mother calls you for advice. "My child got cleaning solution in her eyes and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What do you instruct the caller to do first? 1. Comfort the child and check her vision. 2. Continue to irrigate the eyes with water. 3. Call the Poison Control Center. 4. Call 911 to request an ambulance. Ans: 2 Despite the fact that the child is screaming, the mother must continue to irrigat e the eyes for at least 20 minutes. Another adult, if present, should call the Poison Control Center and 911. Focus: Prioritization A new nurse is caring for a child with a foreign body in the ear canal who has not yet been evaluated by the health care pro vider. You would intervene if the new nurse performs which action? 1. Inspects the pinna for trauma 2. Obtains history for type of object 3. Prepares to irrigate the canal with warm water 4. Uses an otoscope to check for perforation Ans: 3 Vegetable or ins ect matter will swell if water is used for irrigation. Tightly wedged objects such as beads are difficult to flush. If perforation is suspected or if the object is not easily removed, the nurse should not attempt irrigation or instillation. Focus: Prioriti zation You receive the following shift report on an adolescent with anorexia: The patient is 5 kg under her target weight. Her self -esteem has improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize a diet and exercise p lan. What is the priority nursing diagnosis? 1. Imbalanced Nutrition: Less than Body Requirements 2. Disturbed Body Image 3. Risk for Situational Low Self -Esteem 4. Ineffective Health Maintenance Ans: 2 The shift report indicates that the patient still has a disturbed body image; however, she is actively working on gaining weight and improving self -esteem, and has appropriate knowledge that she can use to maintain her health. Focus: Prioritization A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed, and the health care provider has informed the parents that surgery is the next step. Which finding should be reported immediately before surgery proceeds? 1. Palpable sausage -shaped abdominal mas s 2. Passage of normal brown stool 3. Passage of currant jelly -like stools 4. Frequent nausea and vomiting Ans: 2 Passage of brown stool indicates resolution of the intussusception, so surgery may not be necessary. The other findings are part of the clinic al presentation of this disorder. Focus: Prioritization A parent calls the emergency department (ED), saying "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the most essential question to a sk the caller? 1. "Has he vomited?" 2. "Have you been checking his stools?" 3. "What do you think he swallowed?" 4. "Has he been coughing?" Ans: 4 Even though the caller reports that the child is "breathing okay," additional questions about possible airway obstruction are the priority (i.e., coughing, gagging, choking, drooling, refusing to eat or drink). Gastrointestinal symptoms should be assessed but are less urgent. The type of foreign body, in the absence of symptoms, may dictate a wait -and-see approac h, in which case the parent would be directed to check the stools for passage of the foreign body. Focus: Prioritization You are teaching a group of day -care workers about how to avoid transmission of hepatitis A in day -care settings. What is the single mo st effective measure to emphasize? 1. Hand hygiene should be performed often to prevent and control the spread of infection. 2. Children in whom hepatitis has been diagnosed should not share toys with others. 3. Children with episodes of fecal incontinence should be isolated from others. 4. Immunizations are recommended before children are admitted into day -care settings. Ans: 1 Hand washing is the most important aspect to emphasize. Addressing fecal incontinence and sharing of personal items may be recomme nded when the disease is in an infectious stage. Immunizations are recommended, but this would be emphasized to parents rather than day -care providers. Focus: Prioritization These medications have been prescribed for a 9 -year-old with deep partial - and ful l-thickness burns. Which medication is most important to double -check with another licensed nurse before administration? 1. Silver sulfadiazine (Silvadene) ointment 2. Famotidine (Pepcid) 20 mg IV 3. Lorazepam (Ativan) 0.5 mg PO 4. Multivitamin (Centrum Ki ds) 1 tablet PO Ans: 3 Oral sedation agents such as the benzodiazepines are considered high -alert medications when ordered for children, and extra precautions should be taken before administration. Many facilities require that all medications administered to pediatric patients be double -checked before administration, but the lorazepam is the most important to double -check with another nurse. Focus: Prioritization You are caring for a 5 -year-old whose mother asks why he still wets the bed. What is your best response? 1. "He is old enough that he should no longer be wetting the bed." 2. "Most children outgrow bed -wetting by the time they start school." 3. "His bed -wetting may be due to an immature bladder or deep sleep pattern." 4. "He will probably stop once he realizes how embarrassing it is to wet the bed." Ans: 3 Theories about bed -wetting relate it to immature bladder and deep sleep patterns. Although it is true that most children stop bed -wetting by the time they start school, this does not answer the mot her's question. Many boys wet the bed until after the age of 5. The fourth response is not accurate, because often bed-wetting is not within the control of a 5 -year-old child. Focus: Prioritization Which intervention for the 5 -year-old child who still wets the bed would be best assigned to the UAP? 1. Reminding the child to use the bathroom before going to bed 2. Teaching the mother about moisture alarm devices 3. Administering the prescribed dose of imipramine (Tofranil) 4. Discussing research related to t he use of hypnosis with the mother Ans: 1 Reminding the child about something that has already been taught is within the scope of practice for a UAP. An LPN/LVN could administer the oral medication. Teaching and discussion of other strategies for