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Question 1
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. How should the nurse initially collect data about Mrs. Soo Lee’s situation? *1) Ask Mrs. Soo Lee and her daughter to describe changes Mrs. Soo Lee may have recently experienced. Rationale: Basic therapeutic communication requires the establishment of a respectful relationship with the client in order to obtain assessment data. 2) Ask Mrs. Soo Lee’s daughter to translate the nurse’s questions and Mrs. Lee’s answers. Rationale: Approaching the daughter first assumes the mother is incapable of communicating and establishing a relationship. Interview Mrs. Soo Lee’s family members to explore their perceptions of the situation over the past few months. Rationale: Involving all the members of the family would be excessively confusing for the client with Alzheimer’s. Have Mrs. Soo Lee’s daughter describe the changes she has seen in her mother. Rationale: Having the daughter describe the changes observed in Mrs. Lee may be valid but would not be the first step.

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References: Ignatavicius, D. D. & Workman, M. L. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.) St. Louis, Missouri: Elsevier Saunders, p. 965-967. Black, J. M. & Hawks, J. H. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.) St. Louis, Missouri: Elsevier Saunders, p. 2167. 2

Question 2
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. What suggestion should the nurse make to the family in order to promote Mrs. Soo Lee’s safety in the home? 1) Ensure all exit doors are securely locked. Rationale: Wandering does not occur until the later stages of Alzheimer’s. Locking her in is likely to interfere with independence and self esteem. 2) Arrange to have Mrs. Soo Lee supervised at all times. Rationale: Early stage Alzheimer’s may be forgetful but can function with some degree of independence.

*3) Identify and eliminate potential hazards in the home. Rationale: Falls are common causes of injury in the elderly. 4) Do not allow Mrs. Soo Lee to use any electrical appliances. Rationale: Early stage Alzheimer’s does not require this level of restriction of activities. Normal activities of daily living should be encouraged as long as possible.

References: Ignatavicius, D. D. & Workman, M. L. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.) St. Louis, Missouri: Elsevier Saunders, p. 970-972. Black, J. M. & Hawks, J. H. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.) St. Louis,

Missouri: Elsevier Saunders, p. 2169. 3

Question 3
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. Mrs. Soo Lee’s daughter reveals to the nurse that her mother has become increasingly frustrated and angry in the last 2 weeks. Which of the following explanations by the nurse would best assist the family in understanding Mrs. Soo Lee’s change in behaviour? 1) Making demands on Mrs. Soo Lee will lead to further agitation. Rationale: This response is too general to be helpful. 2) Frustration may be eased by performing complex tasks for Mrs. Soo Lee. Rationale: Performing tasks for her may decrease her self esteem and increase her frustration. Mrs. Soo Lee’s outbursts are characteristic of the illness and are predictable. Rationale: Making excessive demands on Alzheimer’s clients may lead to aggressive behavior.

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*4) Mrs. Soo Lee’s behaviour could be due to her awareness that she cannot remember. Rationale: Helping the family to understand the changes in Mrs. Lee may assist them to avoid unreasonable demands. Acceptance of this change in behavior is important in dealing with clients with Alzheimer’s. References: Stuart, G. W. & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.) St. Louis, Missouri: Elsevier Mosby, p. 466. Smeltzer, S. C. & Bare, B. G. (2004). Brunner and Suddarth’s textbook of medical-surgical nursing (10th ed.) Philadelphia, PA, Lippincott-Raven. 4

Question 4
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. Mrs. Soo Lee becomes anxious and distracted during mealtime with the family and seldom finishes her meals. What suggestion should the nurse give to the family? *1) Family members should speak one at a time during mealtime. Rationale: Each member of the family cooperates in a unified approach which reduces noise, confusion and sensory overload for Mrs. Lee. 2) Mrs. Soo Lee’s daughter should guide the mealtime conversations. Rationale: This puts unnecessary stress and responsibility on the daughter. The whole family needs to share the responsibility. Mrs. Soo Lee should have her meals in a separate room. Rationale: This discourages family interaction and is likely to make Mrs. Lee feel isolated. The grandchildren should be encouraged to speak Mandarin during meals. Rationale: This would not help Mrs. Lee to become less distracted at meal time. The family needs to interact, but in a calm, organized way.

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References: Ignatavicius, D. D. & Workman, M. L. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5 th ed.) St.

Louis, Missouri: Elsevier Saunders, p. 968-969. Smeltzer, S. C. & Bare, B. G. (2004). Brunner and Suddarth’s textbook of medical-surgical nursing (10th ed.) Philadelphia, PA, Lippincott-Raven. 5

Question 5
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. Mrs. Soo Lee’s daughter expresses to the nurse that the family and Mrs. Soo Lee prefer to use traditional Chinese medicine. What is the nurse’s most appropriate response? 1) “It is understandable that you would want to consider other treatment alternatives.” Rationale: This acknowledges the family’s wishes but does not encourage further exploration of meaning. 2) “I understand your reluctance to accept Western medicine though it offers the best hope for a quality life.” Rationale: This response makes an assumption about the family’s reluctance and reflects the nurse’s perspective on both “quality of life” and Western medicine.

*3) “I would like to know more about your beliefs regarding health and illness.” Rationale: This response shows cultural sensitivity and opens the opportunity for the daughter to provide and clarify cultural beliefs. 4) “A combination of Western and Chinese medicine might be appropriate to meet everyone’s needs.” Rationale: This response offers the nurse’s perspective without hearing the family’s beliefs and rationale.

References: Shives, L. R. (2005). Basic concepts of psychiatric-mental health nursing (6th ed.) Philadelphia, PA: Lippincott, Williams and Wilkins, p. 367-368. Kozier, B., Erb, G., Berman, A. J., Burke, K., Bouchal, D. S. R., & Hirst, S. P. (2004). Fundamentals of nursing: The nature of nursing practice in Canada.Toronto: Prentice Hall, p. 177. 6

Question 6
Mrs. Soo Lee, 80 years old, widowed, lives with her daughter, son-in-law, and two grandchildren. Her daughter and son-in-law work full-time outside of the home. The two grandchildren attend university full-time. Mrs. Soo Lee has been recently diagnosed with early stage Alzheimer’s disease. She speaks English but has been using Mandarin more and more in all her communications in the last 3 months. A non-Mandarin speaking nurse has been assigned to assess how Mrs. Soo Lee and her family are coping with this situation. Mrs. Soo Lee tells the nurse about feeling lonely during the day. Which one of the following actions by the nurse would best address these concerns? 1) Encourage family members to spend more time with Mrs. Soo Lee during the day. Rationale: Family members may have difficulty addressing psychosocial needs of the client with Alzheimer’s disease. They may not have additional time to spend with the individual. *2) Explore with Mrs. Soo Lee and her family the possibility of participating in community programs for persons with Alzheimer’s disease. Rationale: Access to community resources may support family members in better addressing needs of the client with Alzheimer’s disease in the home setting. 3) Provide Mrs. Soo Lee and family members with information on in-patient care for persons with Alzheimer’s disease. Rationale: This distractor assumes that admission to an in-patient facility is the most effective way of addressing the client’s needs. It may not be the wish of the family or client. Consideration of in-patient care is premature at this point. Reassure Mrs. Soo Lee and her family that this is a common concern for elderly persons.

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Rationale: This distractor does not address the concerns expressed by the client. References: Stuart, G. W. & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.) St. Louis, Missouri: Elsevier Mosby, p. 468. Black, J. M. & Hawks, J. H. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.) St. Louis, Missouri: Elsevier Saunders, p. 2169-2172. 7

Question 7
A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). People involved in this group include people living with HIV/AIDS, their family and friends, and interested individuals from the community. A nurse from the HIV/AIDS clinic is working with this group within the community. The group is currently addressing the need for an AIDS hospice within the community. Group members are in conflict over the need for such a facility. Which of the following actions by the nurse would be most useful in assisting this group to address this issue? 1) Providing data on the number of individuals in the community who have AIDS. Rationale: Although this information would be useful for the current situation, it would not likely address future needs and is only one piece of information needed to support the decision-making. *2) Encouraging an assessment of the needs of the community for this type of facility. Rationale: A community assessment process is a much broader assessment tool to explore the issue more fully within the context of the community and its health service needs. 3) Evaluating the effectiveness of care provided to persons within the existing facilities. Rationale: Although the effectiveness of care with the current health facilities is useful information, it doesn’t address future needs of this segment of the community. Contacting local health services officials to determine their willingness to provide funding. Rationale: Community groups often need to lobby officials to identify needs for additional services. A proper needs assessment would provide rationale for the funding request.

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References: Hitchcock, J. E., Schubert, P. E. & Thomas, S. A. (2003). Community health nursing: Caring in action (2nd ed.) New York: Thomson Delmare Learning, p. 312. Stamler, L. L. & Yiu, L. (2005). Community health nursing: A Canadian perspective. Toronto: Pearson Prentice Hall, p. 156. 8

Question 8
A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). People involved in this group include people living with HIV/AIDS, their family and friends, and interested individuals from the community. A nurse from the HIV/AIDS clinic is working with this group within the community. Group members continue to be in conflict over the appropriate course of action regarding the AIDS hospice. Which of the following actions by the nurse would best assist members to resolve their conflict? 1) Encourage members to vote on the appropriate course of action. Rationale: Members are often unable to listen actively to opposing views when they are in dispute. A mechanism for examining opposing opinions is most useful. 2) Encourage individuals with similar opinions to support one another. Rationale: This strategy is more likely to polarize members and support them in current opinions rather than in resolving the conflict. Encourage members to state their own views in greater detail. Rationale: This strategy may add to understanding of the position but more frequently results in more strongly stated

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p. & community practice (6th ed. What type of information would be most useful to this group in their planning for the hospice and the programs to be offered? 1) The number of individuals diagnosed with HIV in the community Rationale: This information is useful to determine possible future need for service but omits the characteristics of those needing service. A nurse from the HIV/AIDS clinic is working with this group within the community. 673. but is not directly related to the needs of members of this community. W. A nurse from the HIV/AIDS clinic is working with this group within the community. (2002). Which of the following activities by the nurse would encourage the group to assume ownership for the development of their proposal for a hospice? 1) Contact local media to publicize the group’s efforts. p. thus encouraging agreement. A. but should come from the group. J. & Spradley. M.) Philadelphia. Community health nursing: Concepts and practice (5th ed.454-467. *4) Encourage members to examine the values underlying the various positions. D. 190. A. p. and interested individuals from the community. Comprehensive community health nursing: Family.) St. Rationale: The nurse’s action takes away from the group’s decision-making concerning their plans.) Philadelphia.) St.. 9 Question 9 A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). their family and friends. Allender. L. References: Stuart. B. 10 Question 10 A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). G. S. Louis. & Eigsti. (2001). People involved in this group include people living with HIV/AIDS. PA: Lippincott. 2) Arrange for group members to interview influential community persons. Missouri: Elsevier Mosby. *2) Local demographic information about individuals with HIV/AIDS Rationale: This data is most likely to provide both numbers of individuals affected and their characteristics as a basis for program planning. (2001). Rationale: The nurse has decided on a particular course of action which may be beneficial. 364. (2005).positions without resolution of conflict. W. J. Rationale: This strategy encourages the whole group to examine values and beliefs underlying each stated position and to identify common values to be acted on. PA: Lippincott. S. Louis. B. their families and friends. People involved in this group include infected individuals. Common modes of transmission and effective treatments Rationale: This research information likely has little relevance to programs and services offered to those who are experiencing AIDS. Allender. & Laraia. aggregate. This action must be followed by group examination of the stated positions. and interested individuals from the community. p. G. 3) Grants available for health services and programs offered in other communities Rationale: Research on programs in other communities could be very useful. 4) References: Clemen-Stone. . & Spradley. Missouri: Mosby. McGuire. W. Principles and practice of psychiatric nursing (8th ed. T. Community health nursing: Concepts and practice (5th ed.

a group member.) Philadelphia. References: Clemen-Stone. Rationale: The nurse has decided on a course of action for the group which may remove decision-making from the group. 12 Question 12 A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). the group can then decide what type of hospice would best suit their needs. J. Community health nursing: Concepts and practice (5th ed. Louis. G. 3) Provide current research information about modes of transmission of HIV. Marie Jameson. 490-491. their families and friends. has recently been diagnosed as seropositive for HIV. 143. p. A. 76-78. Rationale: Assuming the learner’s needs for information may result in information being presented to the learner . Community health nursing: A Canadian perspective. L. W. People involved in this group include infected individuals. References: Stamler. Rationale: By arranging for the group to connect with other hospices. aggregate. 4) Contact local politicians to assist the group with their proposal. A nurse from the HIV/AIDS clinic is working with this group within the community. McGuire. Potter. & Eigsti. A nurse from the HIV/AIDS clinic is working with this group within the community. & community practice (6th ed. It would be more beneficial for the group to contact other persons. & Spradley. *3) Financial stability and support Rationale: This is a social determinant of health which has impact on the progress and outcome of the illness. 11 Question 11 A group of people have been meeting to support individuals who are seropositive for Human Immunodeficiency Virus (HIV) or who have Acquired Immunodeficiency Syndrome (AIDS). People involved in this group include infected individuals. Jim. B. (2005). Canadian fundamentals of nursing (3rd ed. (2002). Which of the following is the most effective strategy for teaching this information? 1) Provide her with pamphlets describing standard (universal) precautions in the home setting. L. p. Which of the following is a social determinant of health for these individuals? 1) Mode of transmission of HIV Rationale: Not a social determinant of health. Comprehensive community health nursing: Family. L. and interested individuals from the community.) Toronto: Elsevier Mosby.) St. Allender. & Perry. S. asks the nurse about prevention of transmission of HIV among family members. Her son. p. Missouri: Mosby. and interested individuals from the community.*3) Assist the group to connect with hospices in other communities. 4) Gender and ethnic background Rationale: Not a related social determinant of health for HIV. A. Rationale: The learning situation is most effective when the nurse responds directly to learner questions and allows the learner to guide the learning situation through her questions. Toronto: Pearson Prentice Hall. G. A. P. 7-11. and begin the planning of their proposal. S. *2) Begin by answering Marie’s questions about prevention of transmission of HIV. & Yiu. (2001). their families and friends. L. D. The group members have been discussing the factors that influence the health outcomes of individuals who have AIDS. p. 2) Presence of Pneumocystis carinii pneumonia Rationale: Not a social determinant of health.. Rationale: Use of pamphlets is an excellent means of reinforcing learning but should not take the place of the nurse’s teaching role. PA: Lippincott. (2006).

Louis. Rationale: The catheter should be irrigated and the physician consulted before discontinuing and reinserting it. G. Chalmers. Which of the following actions should the nurse do? *1) Assess the catheter drainage system for patency.. Williams. Inform him that this is expected and encourage him to relax. Chalmers. & Perry. L. 3) AFP Rationale: Alpha (sign)-fetoprotein .. & Wilkins. During the nursing assessment. & Bare. He also states that he does not feel his bladder is empty after he voids. 53 years old.elevated with prostatic cancer and benign prostatic hyperplasia. Erb.) Toronto: Elsevier Mosby. S. A. A. R.) Philadelphia. and is experiencing pain when he urinates.J. and is experiencing pain when he urinates. Rationale: The feeling of abdominal fullness is not normal with a patent Foley catheter. 4) References: Ignatavicius. CEA Rationale: Carcinoembryonic Antigen . Medical-surgical nursing: Critical thinking for collaborative care (5th ed. p. 2) Increase his fluid intake for the next 2 hours. p. Based on the information obtained from the client. Rationale: The nurse should respond to learner questions before referring clients to more extensive and independent sources of information which may be less useful to the learner. Burke. he tells the nurse that he has had blood in his urine for several weeks. A . p. Blood work and a cystoscopy confirm the diagnosis of cancer of the prostate. Chalmers undergoes a radical prostatectomy and returns to his room with a three-way urinary catheter with bladder irrigation. Mr. PA: Lippincott. B. K. Fundamentals of nursing: The nature of nursing practice in Canada. During the nursing assessment. Six hours postoperatively. Bouchal. 220. References: Potter. is urinating frequently. Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed. 3) 4) References: . (2004). Kozier. Rationale: The problem is not inadequate fluid intake. Smeltzer. (2004). G. P.) St. (2006).elevated with liver cancer. B. which of the following lab results should be expected to return abnormally elevated? 1) HCG Rationale: Human Chorionic Gonadotropin . 13 Question 13 Mr.unnecessarily and redundantly. P.elevated in ovarian and testicular cancers. Toronto: Prentice Hall. is urinating frequently. 4) Refer Marie to library resources that describe various infection control measures. 14 Question 14 Mr. Blood work and a cystoscopy confirm the diagnosis of cancer of the prostate. S. D. 1497. Rationale: Clots may form in the bladder and block the flow of urine postoperatively. *2) PSA Rationale: Prostate Specific Antigen . D. Mr. 328. G. M. Berman. 53 years old. p. & Workman. S. Canadian fundamentals of nursing (3rd ed. colorectal and lung cancers. 681-685. Missouri: Elsevier Saunders. 1865-1866. & Hirst.elevated in breast. (2006).. is admitted to the hospital. he tells the nurse that he has had blood in his urine for several weeks. Chalmers reports a feeling of fullness in his abdomen and states that he has the urge to void. D. is admitted to the hospital. He also states that he does not feel his bladder is empty after he voids. Remove and reinsert the catheter. C... but a blocked catheter.

G. Chalmers. D. is urinating frequently. and is experiencing pain when he urinates. Based on this assessment. Medical-surgical nursing: Critical thinking for collaborative care (5th ed. P 82. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed. During the nursing assessment.) St. The nurse assesses Mr.) Philadelphia. Chalmers is receiving morphine via a Patient Controlled Analgesia (PCA) pump. (2004). 1506-1507. (2006). D. 1264-1265.) Philadelphia. but rouses easily. C. Williams. he tells the nurse that he has had blood in his urine for several weeks. A.surgical nursing (10th ed. 1862-1864.” Rationale: This response provides accurate information to the client’s wife. & Wilkins. he tells the nurse that he has had blood in his urine for several weeks. on a demand dosage schedule.. D.g. 2) “It would be helpful if you record the frequency of his morphine use. Chalmers tells the nurse that she is concerned that her husband will overdose himself. Missouri: Elsevier Saunders. “There is not enough morphine in the pump to cause serious harm. Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed. He states that he is feeling comfortable. Which of the following is the best response by the nurse? 1) “If you prefer. Rationale: These are normal side effects of morphine and the client should continue to be monitored for any adverse effects (e. & Workman. Rationale: The client’s vital signs and physical status do not warrant discontinuing his PCA infusion. what should the nurse do? 1) Turn the PCA pump off. D. The nurse notes the following: BP 98/62 mmHg. p. Canadian fundamentals of nursing (3rd ed. Blood work and a cystoscopy confirm the diagnosis of cancer of the prostate. further respiratory depression). . (2006). the nurse could administer his medication. (2004). & Perry. Missouri: Elsevier Saunders. & Bare.Ignatavicius. (2006). B. Louis. A. is admitted to the hospital. M. & Bare. L. 53 years old. 16 Question 16 Mr.L. Louis. p. drowsy. Smeltzer. p. M. During the nursing assessment.) St. Louis.) Toronto: Elsevier Mosby. Williams. p.” Rationale: The PCA syringe does hold enough medication to cause serious adverse effects. & Workman. & Workman. Chalmers. He also states that he does not feel his bladder is empty after he voids. p. 15 Question 15 Mr. Medical-surgical nursing: Critical thinking for collaborative care (5th ed. Chalmers response to his morphine. Rationale: The client’s vital signs and physical status do not warrant physician intervention at this time. D. Mr. References: Ignatavicius. B. R 14. Smeltzer. Notify the physician of the client’s vital signs. p. is urinating frequently. S. and is experiencing pain when he urinates. Mrs. PA: Lippincott. 2) Decrease the dose of the morphine. References: Ignatavicius. 351-352. M . He also states that he does not feel his bladder is empty after he voids. 352-353. P. G. 3) *4) “The pump is programmed to prevent morphine overdosage. & Wilkins. 53 years old. PA: Lippincott.) St. Brunner & Suddarth’s textbook of medical. G. Missouri: Elsevier Saunders.” Rationale: PCA records the frequency and this does not address her concerns. S.” Rationale: This would not be the first option available and does not include the client. Rationale: The client’s vital signs and physical status do not warrant decreasing the amount of the medication. 3) *4) Continue routine assessment of the client. D. 235-236. Potter. is admitted to the hospital. L. C. Blood work and a cystoscopy confirm the diagnosis of cancer of the prostate.

R. Mr. a 19-year-old student.1500. 3) 4) References: Shives. Respect his wishes and leave him alone in his room. Louis. which may promote a trusting relationship.17 Question 17 Mr. abruptly dropped out of college and returned home. Medical-surgical nursing: Critical thinking for collaborative care (5th ed. What is the nurse’s most appropriate response? *1) Ask him if he would like dinner brought to him in his room. (2005). He has not washed or changed his clothes in the last 5 days. W. the nurse suggests to Mr. Blood work and a cystoscopy confirm the diagnosis of cancer of the prostate.) St. p. Philadelphia. Principles and practice of psychiatric nursing (8th ed. & Wilkins.). S. Louis. L. Missouri: Elsevier Saunders. is urinating frequently. A voluntary client cannot be forced to participate in treatment. M. this response fails to show an appropriate level of therapeutic concern. C. 250. he tells the nurse that he has had blood in his urine for several weeks. 2) Remind him that socializing with others is part of his therapy. & Laraia. Mr. Mr. but at this early stage he is likely too anxious to be in the company of many other people in what is still a strange environment. and unable to sleep. p. 406. B. Williams and Wilkins. James. M. D. Mr. PA: Lippincott. He is anxious. Rationale: His failure to eat one more meal is not dangerous at this time. G. T. How should the nurse respond to Mr. Rationale: While this respects his wishes. (2006).) Philadelphia.” Rationale: This response makes the assumption that the client is impotent. restless. Suggest to him that not eating is unhealthy. His parents take him to the family doctor. PA: Lippincott. James is admitted to the psychiatric ward of the local hospital as a voluntary client. Stuart. 18 Question 18 Mr.” Rationale: This response would not promote an open discussion with the client regarding his concerns. 4) References: Ignatavicius. p. At dinner time on his first hospital day. . 53 years old. They say that he appears to be listening to and responding to voices that no one else can hear. and is experiencing pain when he urinates. stating that his behaviour is increasingly bizarre. D. Basic concepts of psychiatric-mental health nursing (6th ed. During the nursing assessment. James that he wash his face and change his shirt before he joins the other clients in the dining room. (2004). I’m afraid of what they may make me do”. *2) “What have you been told regarding the effects of your surgery?” Rationale: Assesses the client’s knowledge base prior to health teaching. Williams. G. Chalmers’ question? 1) “You will need to discuss this further with your doctor. James says he wants to stay in his room.) St. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women. 3) “There are many other ways of experiencing sexual intimacy. & Workman. Chalmers asks the nurse if he will be able to have sexual intercourse with his wife when he recovers from his surgery. & Bare.1860. Missouri: Elsevier Mosby. He also states that he does not feel his bladder is empty after he voids. Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed. (2005). He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. Rationale: This is true. p. “Were you experiencing problems prior to surgery?” Rationale: This does not answer the client’s question or address his concerns. Any suggestion of pressure to comply may increase his anxiety and exacerbate his problems. Smeltzer. is admitted to the hospital. Chalmers. Rationale: This shows appropriate concern and a respect for his decision. L.

and unable to sleep. and fearful. 249-252. T. For the first 2 days of his hospitalization. “I don’t hear any other voices in this room. James is admitted to the psychiatric ward of the local hospital as a voluntary client. 20 Question 20 Mr. His parents take him to the family doctor. p. “Your voice is the only one that I can hear.” Rationale: This is not the best response because it fails to clarify the nature of the hallucinations which is an important initial step in their management. This approach tends to decrease the client’s trust and increase his anxiety.” Rationale: This response works toward establishing a trusting relationship because it acknowledges his reality and anxiety. James. 2) “The voices aren’t really there. R. Louis. Rationale: The presence of other people may be too anxiety provoking for him. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women.) Philadelphia. It correctly attempts to establish the nature of his hallucinatory experience before taking other steps in helping him control it. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women. p. Which of the following activities should the nurse suggest for the client at this time? *1) Walking with his primary nurse. abruptly dropped out of college and returned home. Williams and Wilkins. Which answer by the nurse best reflects both a therapeutic and respectful response to his statement? *1) “I don’t hear the voices. stating that his behaviour is increasingly bizarre. Mr. He is anxious. He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. Walking under supervision may be physically and mentally relaxing. restless. He is anxious. Mr. They say that he appears to be listening to and responding to voices that no one else can hear. Mr. I’m afraid of what they may make me do”. (2005). “the voices are with me now. Basic concepts of psychiatric-mental health nursing (6th ed. It is an inappropriate first step to deny their existence. W. abruptly dropped out of college and returned home. He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. Tell me about the voices you hear. 3) 4) . He has not washed or changed his clothes in the last 5 days. It does not respect his experience. & Laraia. Mr. 408-412. James continues to remain agitated. They say that he appears to be listening to and responding to voices that no one else can hear. Rationale: He is too agitated to focus on complex activity. (2005). Playing cards with the nurse. His parents take him to the family doctor.” Rationale: The hallucinations are very real for the client. James tells the nurse. Attending group therapy. Mr. Only you are hearing them. G. James.”. Rationale: This activity requires too much focus and the presence of other people may be anxiety provoking. a 19-year-old student. and unable to sleep. restless. James is admitted to the psychiatric ward of the local hospital as a voluntary client. Mr. I’m afraid of what they may make me do”. Rationale: This activity requires more focus and concentration than he is capable of at present. His agitation would likely disrupt group functioning. PA: Lippincott. Missouri: Elsevier Mosby.19 Question 19 Mr. Stuart. Principles and practice of psychiatric nursing (8th ed.) St. anxious. stating that his behaviour is increasingly bizarre. M. He has not washed or changed his clothes in the last 5 days. It is likely to increase his frustration and agitation. 2) Constructing a jigsaw puzzle. L.” Rationale: Pointing out only that the nurse does not hear the voices will not encourage further discussion of the client’s hallucinations. 3) 4) References: Shives. a 19-year-old student.

abruptly dropped out of college and returned home. Basic concepts of psychiatric-mental health nursing (6th ed. tenses up. oral or injectable. He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. PA: Lippincott. and attempts to punch the other client. 250. I’m afraid of what they may make me do”. and unable to sleep. p. Mr. and moves away. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women. I’m afraid of what they may make me do”. Boyd M. An aggressive approach by the staff may increase the client’s anxiety and escalate the problem. Rationale: This may be necessary if other approaches fail. p. . G. stating that his behaviour is increasingly bizarre. Mr. While in the client lounge he gets into a confrontation with a female client. Missouri: Elsevier Mosby. His parents take him to the family doctor. M. He has not washed or changed his clothes in the last 5 days. Rationale: The client is violent and the nurse needs assistance from other staff in order to restrain Mr. Louis. a 19-year-old student. 21 Question 21 Mr. A. 640-641. Philadelphia: Lippincott. abruptly dropped out of college and returned home. 3) Inform the client he will be put in the seclusion room if he fails to cooperate. They say that he appears to be listening to and responding to voices that no one else can hear. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women. & Laraia.) St. James refuses to let the nurse near him to give the medication. When female staff approach. M. By his fourth hospital day. he clenches his fists. and unable to sleep. What is the best nursing approach for initial management of this incident? *1) Call for assistance. James so he does not hurt himself.References: Shives. Rationale: The client may respond positively to this choice if it is presented in a calm and caring manner. or the staff. Missouri: Elsevier Mosby. James. *2) Offer the client the choice of receiving the medication by mouth or by injection. He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. stating that his behaviour is increasingly bizarre. He is allowed to walk about the nursing unit. L. He punches a hole in the wall. p. Mr. This approach should not be the first option. Principles and practice of psychiatric nursing (8th ed. Mr. restless. Louis. G. & Laraia. R. Rationale: Staff members present should be able to deal with the problem. has been ordered. Mr. T. T. (2002). W. Rationale: The client is experiencing increasing agitation and needs to receive the ordered medication. Sedation. 22 Question 22 Mr. James is admitted to the psychiatric ward of the local hospital as a voluntary client. W. 4) References: Stuart. Psychiatric Nursing: Contemporary Practice. (2005). Williams and Wilkins. Principles and practice of psychiatric nursing (8th ed. James is admitted to the psychiatric ward of the local hospital as a voluntary client. A minimum of 4 people must participate in the procedure in order to safely restrain the client. continues to hear voices. His parents take him to the family doctor. Mr. a 19-year-old student. 2) Attempt to calm the client. Administration of the drug is essential to control the client’s behaviour. but he is not allowed to go outside. He starts to scream and throw furniture.) Philadelphia. Mr. the female client. Stuart. He is anxious. (2005). James. restless.) St. and has become increasingly irritable. Rationale: This crisis situation requires physical restraint of the client for his own protection and the protection of others. but misses. What is the nurse’s most appropriate first action? 1) Ask another nurse to administer the medication to the client. James continues to receive medications to control his anxiety and agitation. James is pacing almost constantly. (2005). He is anxious. 405-407. He has not washed or changed his clothes in the last 5 days. They say that he appears to be listening to and responding to voices that no one else can hear. James’ admission status is changed from voluntary to involuntary. Mr. Respect his right to refuse the medication and report the situation to his doctor.

His parents take him to the family doctor. and too generic to be useful. a 19-year-old student. Rationale: This allows the client to begin to establish a trusting relationship with new people. Rationale: This is likely to be too much information. Principles & practice of psychiatric nursing (8th ed) St. (2002). Louis. He is unlikely to remember essential information if he is overwhelmed with excessive detail. M. Philadelphia: Lippincott. Ford’s doctor has recently treated her for a urinary tract infection using antibiotic therapy. He has not eaten regularly and has lost 10 kg from his normal weight of 75 kg. Ask the female clients to leave the lounge.. Boyd M. restless. Plans are made for his discharge to a semi-independent facility (half-way house) near his family home. stating that his behaviour is increasingly bizarre. Louis. This response omits needed interpretation and clarification by the nurse. Psychiatric Nursing: Contemporary Practice. What is the most appropriate initial intervention to help Mr. Missouri: Mosby. Principles and practice of psychiatric nursing (8th ed. abruptly dropped out of college and returned home. His family may not be able to address his issues and concerns. but this response neglects the protection of the client. Boyd M. James’ condition improves sufficiently to allow him to have his admission status returned to a voluntary one. I’m afraid of what they may make me do”. 3) 4) References: Stuart. 23 Question 23 Mr. Mr. They say that he appears to be listening to and responding to voices that no one else can hear. M. 2) Arrange for Mr. James about the half-way house. T.3) Physically restrain the client. 24 Question 24 Mrs. He is anxious. and may increase the client’s anxiety. and unable to sleep. the client should be supported by nursing staff he already knows when he is first introduced to new people and a new environment. Missouri: Elsevier Mosby. Philadelphia: Lippincott. This should enhance his success at the new facility. Mr. (2005). which is proceeding normally. Rationale: Other clients should be protected.) St. James make a positive transition from the hospital to the community facility? *1) Make arrangements for Mr. Rationale: This strategy is a good method of reinforcing teaching once the nurse has identified the learning needs of the client. G. . G. James and his family as much information as possible about half-way houses and their purposes. & Laraia. 4) References: Stuart. He has not washed or changed his clothes in the last 5 days. is at 34 weeks gestation with her first pregnancy. James. 645. Rationale: Recovered clients may not be very good sources of initial information. while still receiving support and clarification from familiar staff. & Laraia. Mrs. 32 years old. (2002). She asks the nurse how to avoid urinary tract infections in the future. W. This strategy by-passes appropriate assessment of learning needs. James is admitted to the psychiatric ward of the local hospital as a voluntary client. James and his assigned counsellor from the half-way house to meet at the hospital before the client is discharged. She and her husband are attending prenatal classes. (2005). Rationale: Ideally. Their own experiences may or may not be positive. A. *2) Explore what she knows about urinary tract infections. James tells the physician that he is very frightened and wants to go to hospital because the “voices hate women. Rationale: The nurse needs the assistance of at least 4 other people in order to physically restrain the client. Ford. Give Mr. T. Have another client who has used this facility come to talk with Mr. A. p. Which initial action would be most appropriate for the nurse to take? 1) Provide her with a pamphlet on urinary tract infections. Psychiatric nursing: Contemporary practice. W. James and his family to have a tour of the half-way house when he is discharged from the hospital. Mr.

A. women who eat small amounts of meat will produce adequate breast milk. 3) Explain to her that antibiotics do not cross the placental barrier. is at 34 weeks gestation with her first pregnancy. p. 32 years old. A & Perry. and that she needs to be taught all information. S. Berman.” Rationale: Eating additional calories will not ensure quality breast milk in the absence of ingesting adequate amounts of protein 2) “The quality of breast milk is not affected by the amount of meat in the diet. 32 years old.) Philadelphia: Lippincott. 4) References: Kozier. Rationale: This would be appropriate information to give to Mrs. P. p. Ford’s learning needs. Mrs. which is proceeding normally. Ford. A. A. Rationale: This response might be appropriate but negates the nurse’s responsibility to provide evidence-based information. Pillitterri A. Ford’s current level of knowledge prior to teaching information. 4) References: Potter.) Toronto: Elsevier Mosby. The content taught should be specific to Mrs. 26 Question 26 Mrs. 323. it doesn’t address Mrs. Rationale: Although this statement is usually true.. Potter. Williams & Wilkins. G. Rationale: This approach assumes that Mrs. Ford. G.. G. (2007). (2006). P. p. Canadian fundamentals of nursing (3rd ed. P. Review with her the causes of urinary tract infection. She and her husband are attending prenatal classes. R. She is concerned that the medication may have affected her unborn child. B. 327-329. Toronto: Elsevier Mosby. 674-676. Burke.” Rationale: The quality of breast milk would be negatively affected by inadequate levels of protein in the client’s diet. however her knowledge regarding urinary tract infections needs to be assessed first. *2) Discuss with her written information about the drug. It suggests lack of assessment of current knowledge. is at 34 weeks gestation with her first pregnancy..Rationale: The nurse correctly assesses Mrs. “Breastfeeding does not require any modifications in a woman’s usual diet. Ford. Ford’s concern about the safety of the drug for pregnant women. Canadian fundamentals of nursing (3rd ed.” 3) .). Which response by the nurse would be the most appropriate? 1) “With additional calories. Ford asks about the antibiotic drug prescribed to treat her urinary tract infection. Refer her to the pharmacist for further teaching. Ford’s current practices and knowledge are inadequate. Erb. Toronto: Prentice Hall. & Perry.. A. (2006). Ford eats very little meat and is concerned that this will affect her breast milk. D. (2004). J. which is proceeding normally. Bouchal. Rationale: This response provides incorrect information and falsely reassures the client. Mrs. Fundamentals of nursing: The nature of nursing practice in Canada. K. Maternal & child health nursing: Care of the child and the childbearing family (5th ed. 25 Question 25 Mrs. 3) Explain to her that she should increase her fluid intake. & Hirst. Rationale: This action by the nurse is evidence-based and addresses Mrs. Ford’s concern about the drug she was prescribed. She and her husband are attending prenatal classes. S. Which of the following interventions by the nurse is most appropriate? 1) Reassure her that physicians prescribe drugs carefully to pregnant clients.

Telling the client that the physician will be notified so that a change in medication can be made. Louis. Ford has two sons from his first marriage. Williams and Wilkins.) St. Bouchal. G. 27 Question 27 Mrs. M. Maternity and women’s health care e (8th ed. Maternal and child health nursing: Care of the childbearing and the childrearing family (4th ed. p. 2) Informing the client that it takes 4 to 6 weeks to feel his mood and other symptoms improving. but the client should feel a noticeable improvement within the first month.. who live with their mother. (2003). p. *3) “You seem concerned by this situation with your family. Louis. Burke. then the drug will likely be discontinued or changed. which is proceeding normally. 32 years old.. A. *4) “You can replace meat with other sources of protein and maintain a well-balanced diet for breastfeeding. E. Ford confides to the nurse that she and her husband disagree about the involvement of his two sons in their family. She and her husband are attending prenatal classes. B. 685. Toronto: Prentice Hall. 371. Rationale: The therapeutic response begins in the first week. Principles and practice of psychiatric nursing (8th ed. 2) “Are you concerned about not getting along with your husband’s two sons?” Rationale: This response adds content to the statement made by the client and indicates assumptions made by the nurse. Berman. Ford. 30-35. More exploration of the issue is indicated by the client’s statement. W. Teaching the client about the need to exercise daily in order to feel the full benefit of the medication. D. Erb. Mr. Which of the following responses by the nurse would be most therapeutic? *1) Advising the client that it takes 1 to 4 weeks to feel the therapeutic benefit of this medication. Rationale: If there is little improvement in mood and other symptoms after 4 to 8 weeks on a therapeutic dose.Rationale: Breastfeeding requires a well balanced diet and additional calories to support the process of lactation. aged 16 and 19 years. K. 4) “It seems that your husband would like you to involve his sons at this time. Missouri: Mosby. Mrs. L.. & Perry. Stuart. & Hirst. & Laraia. Missouri: Elsevier Mosby.” Rationale: If the client does not eat meat. 8 Question 28 A 60-year-old male client with a diagnosis of depression tells the nurse that the paroxetine (Paxil) he has been on for the past 1 week is not helping. S. He states that he still feels depressed and lacks energy. (2004). References: Lowdermilk. P.” Rationale: This statement correctly indicates acceptance of the content and feelings expressed and encourages further discussion of the issue. T. J. Fundamentals of nursing: The nature of nursing practice in Canada. A.. is at 34 weeks gestation with her first pregnancy. D. Pillitterri. p.” Rationale: This response is judgmental and conveys the nurse’s position on the client’s problem. S. Her husband wants to invite his sons to spend the summer with them. S. (2005). p. Which of the following responses by the nurse would be most appropriate? 1) “How would you like to deal with this situation?” Rationale: This statement forces the client to discuss specific approaches when she may not be ready to do so. References: Kozier. R.) St.. PA: Lippincott. G. Rationale: The client should know that there is a lag time before a therapeutic response occurs. 492-493. (2004).) Philadelphia. 382-383. 3) 4) . other sources of protein can be consumed to ensure quality breast milk.

(2004). Compendium of pharmaceuticals and specialties. L. Williams and Wilkins.. Ensure that participants make independent decisions. Mrs. Wong’s nursing care of infants and children (7th ed. D. PA: Lippincott. Ottawa: Author. Rationale: One hallmark of adolescence is the value and importance of friendships and relationships with peers as a means of developing self identity. Ford’s concerns. it would have no effect on the pharmacological action of the antidepressant. Clinical pharmacology & nursing management (5th ed.A.W. S. Maternal and child health nursing: Care of the childbearing and the childrearing family (4th ed. J. 3) *4) Plan learning activities that involve peer support. M. Rationale: Independent decision making is an important developmental transition in this age group though they must first have the knowledge to make appropriate decisions. 32 years old. Ford. D L. Missouri: Mosby.. Ford’s concerns without exploring the nature of these concerns. (2003). p. Rationale: This approach assumes a solution to Mrs.) St.). Maternity and women’s health care (8th ed. Sedation should be used cautiously with pregnant women. She and her husband are attending prenatal classes. 4) Encourage her to discuss bedtime sedation with her physician. . A. Pillitteri. (1998). New York: Lippincott. 402 Canadian Pharmacists Association. St. Rationale: Puberty is an issue for adolescents but this is not an appropriate focus or context. the adolescent is in need of developing an identity and autonomy. 1259. Ford’s concerns prior to initiating action. Rationale: The nurse needs to explore Mrs. F. 2) Provide her with information on positions that promote sleep. Which action by the nurse would be most appropriate? 1) Explore with her the possible use of epidural analgesia for labour. L. Rationale: Although it is important that parents are informed regarding the care of their diabetic child. However. p. Ford tearfully explains to the nurse that she is very fearful of labour and is not sleeping well.W. & Bergon. Louis. 30 Question 30 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus). 29 Question 29 Mrs. 2) Plan a class session on the physiology of puberty. It takes the decision-making power away from Mrs. Rationale: This approach assumes a solution to Mrs. (2003). E. Nichols.). References: Lowdermilk. References: Hockenberry. p. Ford and her partner. is at 34 weeks gestation with her first pregnancy. Missouri: Mosby. Louis. p. & Wong.Rationale: Vigorous exercise gives a temporary “high” and is one treatment modality for depression. L. 509. References: Eisenhauer. Which of the following actions by the nurse would best acknowledge the developmental needs of this group? 1) Involve the parents in the education sessions. (2003). Rationale: Sedation will not address her basic concern over labour care. This small group is made up of teens ranging in age from 13 to 15 years. *3) Discuss with her the concerns she has about labour. 438-439. which is proceeding normally. 371.) Philadelphia. A client in the initial phase of treatment for depression would not be a candidate for vigorous exercise and would also be dependent on the client’s physical health. p. & Perry.

M.) St. 25. thus decreasing trust with the nurse. Missouri: Mosby. Williams & Wilkins. Erb. p. Burke. Quizzing may be threatening to some. This small group is made up of teens ranging in age from 13 to 15 years. Kozier. (2004). there is less chance of understanding. Missouri: Elsevier. Wong’s nursing care of infants and children (7th ed. D.. D. 2) Ask each participant to list their needs for information regarding diabetes.. B.. 1745. Missouri: Mosby. . S. Jarvis. Which of the following strategies would be most effective in teaching nutritional management of diabetes? 1) Discussion with handouts Rationale: This may provide necessary information but without discussion regarding rationale. References: Hockenberry. 675. 32 Question 32 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus). S. D. A. M. when the group has a common learning need. Rationale: This may be somewhat overwhelming for the adolescent population as there is a large amount of material to cover. & Hirst. *2) Game on food selection Rationale: Adolescents relate well to peers and group learning. 4) References: Hockenberry.1750-1752. Toronto: Prentice Hall. (2003). 3) Videotape with follow-up quiz Rationale: This method would not necessarily provide the understanding needed and would meet only one learning style. & Wong. (2003). p. it is unlikely that newly diagnosed clients would know what information they might need. which of the following actions should the nurse implement initially? 1) Distribute an outline and sequence of all topics to be addressed.. J. J. L. Presentation by a dietitian Rationale: The use of speakers does not necessarily encourage learner involvement. R. Louis. 1006-1015. Louis. G. Berman. Rationale: Though this may be helpful in establishing some rapport and participation. Fundamentals of nursing: The nature of nursing practice in Canada. Some structure is necessary though this response does not allow for any client collaboration. beginning with insulin administration. & Wong. In planning for teaching the group about diabetes management. This small group is made up of teens ranging in age from 13 to 15 years. Pillitterri.) St. Wong’s nursing care of infants and children (7th ed. Rationale: This response indicates assumptions by the nurse and does not reflect collaboration with the learners.) Philadelphia. Bouchal. Written information is helpful for reinforcement. 1752-1755. K. (2004). p. PA: Lippincott. Physical examination and health assessment (4th ed. p. Identify the priority components of diabetes management. P. L. p.. A. Louis. 31 Question 31 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus). C. (2003). 3) *4) Determine the group’s understanding of diabetes and develop an outline together.). J. Maternal and child health nursing: Care of the childbearing and the childrearing family (4th ed. St. Rationale: Client education should begin with the clients’ understanding and assessment of their individual needs and the learning plan developed collaboratively.

& Wong. D. p. (2003). Missouri: Mosby. Swimming once a week Rationale: This activity is not frequent enough for a regular program. 3) Cycling on weekends Rationale: Cycling would provide good physical exercise but would need to occur more regularly to be effective. Louis. B. L. Maternal and child health nursing: Care of the childbearing and the childrearing family (4th ed. D. is keen to take more responsibility for his care. A. PA: W. L. Saunders. Wong’s nursing care of infants and children (7th ed. 34 Question 34 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus). M. After 4 days of diabetic teaching at the camp. This small group is made up of teens ranging in age from 13 to 15 years. Which of the following activities would best meet the exercise criteria for adolescents with diabetes? 1) Hiking twice weekly Rationale: This activity is not frequent enough for a regular program. (1995).. & Mishler. 35 Question 35 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus).33 Question 33 The camp nurse plans an educational session for a group of adolescents with newly diagnosed diabetes Type 1 (insulin dependent diabetes mellitus). Sean.1892-93.) St. p. M. This small group is made up of teens ranging in age from 13 to 15 years. Williams & Wilkins. A minimum of 45 minutes of sustained activity.) Philadelphia. 1479. p. L. A. (2003). Wong’s nursing care of infants and children (7th ed. 1740. (2003). M. Which one of the following food selections by the group members would indicate to the nurse that they understand how to treat initial symptoms of hypoglycemia? *1) A glass of milk Rationale: Provides 15 grams of carbohydrate. Workman. A can of diet cola Rationale: Diet soft drinks should be avoided as they do not contain sugar. J. It might be taken after the ingestion of a simple sugar to maintain the blood glucose. Pillitterri. planned. 2) An apple Rationale: Fruit is too rapidly absorbed and this amount would not provide adequate simple sugar. D. J. Medical-surgical nursing: A nursing process approach (2nd ed) Philadelphia. & Wong. 3) 4) References: Hockenberry. PA: Lippincott. This small group is made up of teens ranging in age from 13 to 15 years..) St. M. 13 years old. Ignatavicius. Louis. Which . three times a week is necessary for an effective program. *2) Roller blading daily Rationale: One hour of daily exercise provides a regular. p. 4) References: Hockenberry.1749-1750. D. A slice of bread Rationale: Bread is a more complex carbohydrate and will not be absorbed quickly. Missouri: Mosby. moderate activity and would facilitate the lowering of glucose levels. with a rapid release of lactose (simple sugar) followed by a more prolonged action from the protein and fat.

3) “May I call your doctor so that your concern can be clarified?” Rationale: This response does not address the client’s concerns and knowledge level. (2006). Rationale: This response is inappropriate at this point as it takes responsibility from Sean and does not address his needs. S. p. 60 years old. 1476. . M. and makes the nurse appear indecisive and unprofessional. Pillitterri. 8. Wong’s nursing care of infants and children (7th ed. Edwards returns to the unit with an intravenous infusing into a central line in the right subclavian vein. (2006). J. 2) Reviewing Sean’s dietary needs with him. He is admitted to the hospital the morning of his surgery. References: Hockenberry. “That is a common concern. p. S. D. 1752-1755. Toronto: Elsevier. Rationale: This response does address Sean’s need and demonstrates the nurse’s role in assisting Sean with implementing his learning plan. Rationale: This is essential on return to the nursing unit since tubing connections may have been loosened in transport. 36 Question 36 Mr. is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. p. Rationale: This response reflects the nurse’s role but is not meeting Sean’s need for increased responsibility. J.) Philadelphia. Edwards tells his admitting nurse that he is worried he will “wake up with a colostomy”. Mr. and provides opportunity for the nurse to clarify and expand the client’s understanding. Ross-Kerr. Medical-surgical nursing in Canada. M.of the following actions by the nurse would best help Sean to achieve his goal? 1) Reviewing with Sean his blood glucose levels for the last 4 days. 4) References: Lewis. C. Toronto: Elsevier. 37 Question 37 Mr. & Wong. Maternal and child health nursing: Care of the childbearing and the childrearing family (4th ed. 4) Discussing Sean’s plan of care with his parents. Canadian fundamentals of nursing. Edwards. M. and misunderstandings. Edwards. Rationale: This response also does not necessarily meet Sean’s needs for increased responsibility for self care.. *3) Supervising Sean while he prepares and administers his own insulin. p. Heitkemper. this is not the best first response as it fails to firmly establish the actual level of the client’s baseline knowledge. suspicions. What is the nurse’s most appropriate response to this concern? 1) “That is unlikely given the location of your tumour. Clients often become less anxious and able to attend to other aspects once insulin injection technique is mastered. (2003). (2003). What is the most essential action for the nurse to take regarding the central line? *1) Check that all tubing connections on the central line are secure. 184. PA: Lippincott. It is also likely to increase his anxiety. R. M. M.” Rationale: While likely true. is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. J.) St. & Wood. L. *2) “What has your surgeon told you about the planned surgery?” Rationale: This open-ended question elicits further discussion by encouraging the client to recall the physician’s teaching. A. Mr. Missouri: Mosby. 60 years old. Williams & Wilkins. He is admitted to the hospital the morning of his surgery. what would you like to know about colostomies?” Rationale: This response is incorrect because it appears to confirm his doubts. Louis. & Dirksen.

A loose connection can result in an air embolus. p. p. S. Medical-surgical nursing.. Edwards. narcotics. (2006). It indicates the need for more frequent nursing measures. References: Lewis. G. Rationale: The ABG results are not critical and do not warrant contacting the physician immediately. S. Toronto: Elsevier. *3) Assist him to deep breathe and use his incentive spirometer stat and q. distended and .. 2) Put a cool air humidifier at his bedside and remove extra bed clothes. Rationale: Increasing Oxygen flow rates will be unlikely to address the issue of insufficient lung ventilation.45 mmHg) What action should the nurse take after noting these results? 1) Increase the flow rate of oxygen through his nasal cannula to 10 L/min. & Dirksen. 38 Question 38 Mr. G. G. S. M. His arterial blood gas report shows the following results: Values Client results pH PaO2 PaCO2 7. Rationale: The head of the bed can be elevated at any angle and this will not interfere with the flow of the I.45) (80mmHg or greater) (35 . A. & Hawks. p. M.7. J. Clinical nursing skills and techniques. 2) Monitor the solution flow rate every 15 minutes for the first hour. Mr. H. On the morning of his second postoperative day. the nurse observes that Mr. M. He is admitted to the hospital the morning of his surgery. P. Toronto: Elsevier. Techniques in Clinical Nursing. A. anaesthetic agents. A dressing change is not called for unless the dressing has been compromised during client transport. Rationale: The temperature and the blood gas results indicate very mild hypoxemia and respiratory acidosis likely due to retained pulmonary secretions. 1049-1050. Erb. Rationale: Central line dressings are changed according to strict protocols and are never changed unnecessarily. 608. Medical-surgical nursing in Canada. Black. R. Ensure that the head of the bed is not elevated at more than 20 degrees. is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. 60 years old. p. Rationale: All central lines must be placed in I. M. On the morning of his first postoperative day.35 . Edwards’ abdomen is hard. & Snyder. Berman. J. age and immobility and is a common finding on the first post op day. B. & Potter.1h. 3) 4) References: Perry. Toronto: Elsevier. He is alert and his temperature is 38° C at 0800 hours. 60 years old. 305. rate controllers which make q15 min checking unnecessary and wasteful of time. (2006). Edwards has been receiving oxygen by nasal cannula at a rate of 4L/min. 410. Reinforce the dressing over the subclavian insertion site. (2005). Kozier. Rationale: There is no evidence that Mrs. Heitkemper.33 78 mmHg 48 mmHg Normal values (7. Toronto: Prentice Hall. 408. This is secondary to pain.V. 39 Question 39 Mr.. Edwards has thick secretions which cannot be mobilized. 4) Notify the physician immediately of the client’s status. is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. A. (2004). He is admitted to the hospital the morning of his surgery.V. Edwards.

His urine output for the last 2 hours totals 15 mL. Mr. (2005). Edwards? 1) Change the tube feeding solution bag every 72 hours. Which of the following is the most appropriate nursing action in the administration of blood? 1) Allow each unit of blood to warm to room temperature before administration. J. 3) 4) References: Lewis. What is the most appropriate nursing action when administering the tube feeding to Mr. p. 2283. A. He is admitted to the hospital the morning of his surgery. H. Toronto: Elsevier.M. Rationale: This is not essential information at this time. 41 Question 41 Mr. Medical-surgical nursing in Canada. (2006). M. 40 Question 40 Mr. Mr. anxiety. & Hawks. Medical-surgical nursing. Rationale: Each unit of packed cells should infuse in under 4 hours. Rationale: Allowing the blood to warm before infusing contributes to breakdown of components and enhances the likelihood of adverse client reactions. A new bag should be used every 24 . Check peripheral pulses. p. S. M.. The wound drainage device is filled with fresh blood. (2006). R. M. He is admitted to the hospital the morning of his surgery. Toronto: Elsevier. Apply pressure to his abdomen. Rationale: Most serious transfusion reactions (anaphylaxis. Rationale: The results of the assessment necessitate immediate notification of the surgeon. *2) Infuse each unit of blood slowly for the first 15 minutes of the transfusion. 3) Ensure that each unit of blood infuses over a period of 4 . is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. and prevents the client from receiving excessive amounts of the blood product. S. Black. incompatibility) occur within the first 15 mins or the first 50 mL of the transfusion. Rationale: The intravenous tubing needs to be flushed with NS as this is the only solution that is compatible with packed cells. Edwards is unable to meet his nutritional needs postoperatively with a regular diet. He is restless and anxious. 305-310. Rationale: This is not a priority action at this time. H. Heitkemper. 976. A longer time encourages growth of microorganisms and breakdown of components. 60 years old. Blood should be started within 30 minutes of removal from storage. Rationale: After use the bag and tubing is washed to reduce bacterial growth.6 hours. In addition it is likely to increase client pain. M . Flush intravenous tubing with D5W between each unit of blood. Toronto: Elsevier. (2005). J. 4) References: Perry. His pulse is 120/min and respirations are 30/min and shallow. A slow infusion rate acknowledges this. 60 years old.tender. & Hawks. Black. Clinical nursing skills and techniques. Edwards. is scheduled to have a bowel resection for a diagnosis of adenocarcinoma of the transverse colon. Medical-surgical nursing. His blood pressure is 90/60 mmHg. What immediate action should the nurse take? *1) Inform the surgeon. P. Edwards. A. and intra-abdominal irritation and bleeding. The surgeon orders intermittent feedings via a nasogastric (NG) tube. Edwards requires 2 units of packed red cells. J. p. & Potter. 407-421. 2) Check his bladder for distention. Toronto: Elsevier. Rationale: This intervention is incorrect since application of external pressure will not affect intra-abdominal bleeding. G. & Dirksen. J. p.

M . H. A. Rationale: Not the rationale for this question. (2006). Rationale: Tube feeding solutions are given at room temperature. Medical-surgical nursing. diet. M. *2) Bacterium. Rationale: Not the best rationale: Although care needs to be individualized. Rationale: This is an essential safety measure to decrease the likelihood of regurgitation and aspiration of gastric contents. p. S. Stressful lifestyle Rationale: Stress is a risk factor in peptic ulcer disease but is not proven to be a causative factor. 3) To individualize care for the client. (2006). A. 1032. & Potter. the NG tube is flushed with 30 mL of tap water to prevent plugging and discourage bacterial growth. G. Rationale: The data (not the nurse) has to relate to the client’s situation. The nurse asks “Do you exercise at the same time each day and check your sugars before you start?” Which one of the following is the best rationale for the nurse’s response? 1) To ensure the nurse can relate to the client’s situation. “Exercise. H. J. 3) Excessive intake of caffeine and spicy foods Rationale: Research has not supported diet as a cause of gastric ulcer disease though it may be an aggravating factor.J. References: Perry. 2) Flush the NG tube with 60 mL of saline before each feeding. Toronto: Elsevier. Lewis. this occurs when interventions are based on a nursing diagnosis (indirectly accurate data). Toronto: Elsevier. 273. glucose testing.. Medical-surgical nursing in Canada. and insulin work together to control my diabetes”. 3) *4) Keep the head of Mr. pylori Rationale: This bacterium is present in 50-70% of clients with gastric ulcer disease. To organize the data into meaningful clusters. P. p. 4) References: Black. 43 Question 43 Based on research findings. & Wood. & Dirksen. p. Warm the feeding solution before giving it to Mr. (2006). Edwards’ bed elevated during the feeding. It produces an enzyme which interferes with the resistance of the gastric mucosa to gastric juices. 68. C. M. 42 Question 42 A client with diabetes states. p. M. & Hawks. Heitkemper. S. what should the nurse identify as the leading cause of gastric ulcer disease when teaching clients? 1) Hypersecretion of hydrochloric acid Rationale: Recent research demonstrates that only 10% of gastric ulcers show evidence of hypersecretion of HCl. (2005). Edwards. Rationale: Validation involves asking the client to confirm the information obtained. Toronto: Elsevier. Canadian fundamentals of nursing. Ross-Kerr.hours. *2) To validate the data ensuring accuracy. Clinical nursing skills and techniques. 992-994. Validation of data should occur before clustering of information. J. M. Rationale: After every feeding. 4) References: . R. Toronto: Elsevier. J.

Measuring each time ensures a good appliance fit. 3) Place the newly admitted client in a private room.G. RR 22. J. Which nursing intervention is most appropriate for Mr. “I’m going to measure my stoma size each time I change the appliance for about 8 weeks. including two injections for the person admitted. 3) “I’ll expect to see a little bleeding from my stoma when I clean it during appliance changing. has been learning to care for his new ileostomy for the past week. G. 663. M. & Hawks. Heitkemper. S.4h prn prescribed.Lewis. A. p. He has morphine sulfate (Morphine) 10-15 mg s. 4) References: Perry. J. Techniques in clinical nursing. . The client should be taught to empty the pouch when it is no more than half full as the added weight may disrupt the pouch seal and cause leakage. & Potter. BP 160/86. 1037.J. R. Rationale: A threat to client safety is a priority. (2005). Medical-surgical nursing. Starsky. M. 75 years old. but the colleague says that she cannot help at the moment. M. J. Toronto: Prentice Hall. Black. A. Berman. 45 years old.” Rationale: Shrinkage occurs particularly in the first 4-8 weeks. *2) Ask the health care aide to watch the client at risk for suicide. Canadian fundamentals of nursing. M. J. now and reposition him. 4) References: Ross-Kerr. What should the nurse do? 1) Delay distribution of some medications until the situation stabilizes. P. G. p.” Rationale: Some bleeding is normal and client should be taught about this to reduce anxiety. q. *2) “I’m planning to empty the pouch whenever it becomes full.c.c.. Toronto: Elsevier. He asks a colleague to help him perform his duties. Medical-surgical nursing. S. & Dirksen. Toronto: Elsevier. Starsky’s pain management at this time? 1) Administer 10 mg morphine sulfate s. Rationale: This takes time and it is not certain that the colleague will be able to help. Kozier. A.C. (2006). 826. Clinical nursing skills and techniques. H. 9-10. p. 46 Question 46 Mr. J. & Hawks. Toronto: Elsevier. p. Which of the following statements indicates that Mr. 3 hours ago. has returned to the nursing unit following abdominal surgery. another client must be watched for high suicide risk. 1154. He rates his pain at 9 on a scale of 0-10. Review the care priorities and once again ask for the colleague’s help. He is restless. Rationale: Medications need to be administered as ordered and should not be delayed for someone in an acute manic phase. (2006). Toronto: Elsevier. Black. M. In addition. (2004). Robins requires more information from the nurse about ileostomy self-care? 1) “I’ll make a cuff at the pouch opening before emptying it.” Rationale: Appropriate as cuffing the pouch keeps end clean reducing odour. p. 45 Question 45 A nurse on the psychiatric unit admits a client in the acute manic phase of bipolar disorder. & Snyder. M. Robins. 152-155. He received morphine sulfate 10 mg s. H. S. & Wood. Erb.c. P 82. Medical-surgical nursing in Canada. p. B.” Rationale: Shows that he requires teaching interventions regarding pouch emptying. (2006). Rationale: This does not resolve the problem of the medications and the client on suicide watch. (2005). 44 Question 44 Mr... Toronto: Elsevier. The nurse has many medications to administer.

& Dirksen. p. Gerontologic palliative care nursing. Rationale: His order is q. L. at this time and re-assess in 15 min. Agich. & Hawks. He was admitted 3 months ago to a long-term care facility for the elderly. Rationale: Family contact is important for the institutionalized elderly client.. Toronto: Elsevier. Rationale: The female condom acts as an effective barrier to protect against STI. 415-416. *2) Call the physician and ask for a stat order of morphine sulfate. 2) Contraceptive devices protect against sexually transmitted infections. Dependence and autonomy in old age: An ethical framework for long-term care. and then give 15 mg morphine sulfate. Medical-surgical nursing in Canada. Rationale: The goal in pain management is to have the pain relieved before it becomes too severe. Confer with his physician and recommend an antidepressant medication. M. 48 Question 48 What information about safe sexual practice should be included in a presentation to a group of adolescents? *1) The male condom should be applied before vaginal. Which of the following would be the most effective intervention in promoting social interaction for Mr. which may help expedite the grieving process. Toronto: Mosby. He says he feels depressed and is reluctant to leave his room. the client is not provided any choice. W. Rationale: Not all contraceptives protect against STI. Give 15 mg morphine sulfate s. M.Rationale: This dose did not manage his pain for 4 hours. J. The physician would need to order a stat dose of morphine to get his pain under control. coated with spermicidal gel. A post-op client requires regular around-the-clock pain management. His pain is now severe and it would be inadequate for him now. Rationale: This will allow him some time to grieve. Rationale: Medications should not be the first intervention used to improve his mood. Black. (2003). 47 Question 47 Mr. M. and have control over his activities. 3) 4) .c. H. but also will encourage his participation in social activities in the facility. Heitkemper. In addition. Rationale: His pain is too severe at this time and inappropriate to have him wait. D. Medical-surgical nursing. 4h and still an hour before the nurse can legally give it. 173. re-assess his pain. 4) References: Lewis. p. O’Connor is 83 years old. Rationale: Contact with another person’s body fluids around the head or an open lesion on the skin. anus. (2004). The order is q. J. and unable to live on his own. G. 4) References: Matzo. anal or oral contact with the penis. The female condom does not protect against sexually transmitted infections. S. J. and legally the nurse cannot give him the 15 mg now without a new physician’s order. p. M. Toronto: Elsevier. (2005). Rationale: It is important that the client be allowed to go through the grieving process. O’Connor? 1) Notify his family and suggest that they telephone him daily. 149. M. Diaphragms. 3) Schedule him for participation in the facility’s recreational activities. may be inserted 4-6 hours before sexual intercourse. R. *2) Allow him some time alone and encourage him to go to the dining room for his meals. but this does not address his need for social interaction at the facility. recently widowed. 309. (2006). New York: Cambridge University Press. & Sherman.4h. p. or genitalia can transmit a STI. Organized recreational activities may overwhelm the client at this time. 3) Reposition him. S.

A.. L.W.. & Laraia. He confides in the nurse that he wished no one had found him after his fall. Requires a body awareness and comfort with body not common in adolescents. & Ashwill. M. Winkelstein. 49 Question 49 Which of the following safety features should the school nurse recommend to be in place in a children’s playground? 1) A concrete platform under the activity centre Rationale: Activity centres should have resilient surfaces to reduce the impact from a fall. 618. G. Equipment that is no more than one meter from the ground Rationale: This is not reasonable for children’s playground equipment. N. Jones. 2) An open slide that has an incline of not more than 60 degrees Rationale: Open slides should have inclines of no more than 30 degrees. How should the nurse respond? . & Ashwill. J. D. Principles and practice of psychiatric nursing. She tells the nurse that when she is discharged she will go on a strict vegetarian diet. Toronto: Prentice Hall. Community and public health nursing.. M. Toronto: Mosby. Rationale: This requires a multidisciplinary approach and the health care team needs to be informed. He states that since his wife of 45 years died. 14 years old. Murray. Rationale: Delays action and thus does not ensure a proper diet upon discharge. 193-196. L. J. has anorexia nervosa. Concrete is a hard material. James. 86-89. 2) Consults the psychology service. E. *3) Requests a meeting of the health care team. 50 Question 50 Danielle Carter. References: Stanhope. M. p. W. S. 4) Conveys the information to the outpatient clinic team. & Davidson. D. J. E. Toronto: Mosby. Maternal-child nursing. London. Stuart. 51 Question 51 Mr. Toronto: Elsevier. Wong. Rationale: The health care team needs to be informed. Maternal-child nursing. (2006). p. Wilson.. M. & Lancaster. life “has not been worth living”. M. p. Murray.. L. J. (2003).Rationale: Is a true statement about diaphragms however they do not protect against STI.R.. M. T. S. Wong’s nursing care of infants and children. p. Which one of the following shows that the nurse is communicating effectively with the health care team in relation to Danielle’s intentions? 1) Records Danielle’s remarks on the chart. S. 1540-1541.. Toronto: Elsevier. and reduces the possibility of an injury. p. age 71. Hockenberry. Toronto: Elsevier. (2005). References: McKinney. Rationale: Although it should be recorded this does not ensure that action will be taken. (2005). 635. Contemporary maternal-newborn nursing care. & Kline. p. E. Ladewig. James. (2004). 529. (2005). S. has undergone a repair for a fractured hip. sand or wood chips under the swings Rationale: Sand and wood chips provide a soft surface that reduces the impact from a fall from the swings. P. S. 3) *4) Foam. S. References: McKinney..

Canadian fundamentals of nursing. & Trigoboff. By law the nurse must report sexually transmitted diseases. p. References: Lewis. (2006). *3) “I am required to report this communicable disease to the public health authority. 2) Instruct the student nurse to recheck the vital signs in 10 minutes. Toronto: Prentice Hall. Rationale: IV administration has not been ordered. 65 years old. & Sherman. Medical-surgical nursing in Canada. The nurse is not required to tell Jessica’s parents about her diagnosis. Do not have enough information about the client’s condition to do this. C. Toronto: Elsevier. M.W. *3) Recheck the vital signs. Rationale: The student nurse’s vital signs did not match the clinical picture of this client when she took them the first time. the student nurse reports that the vital signs have not changed since earlier in the shift. (2006). “Who has to know about this?” What would be the nurse’s best response? 1) “Don’t worry.. is a post-operative client who suddenly develops hemataemesis. 4) Administer a bolus of 200 mL of normal saline I. Wilson. diaphoretic and says she feels faint.” Rationale: This is a false statement.. Ask him how he was managing at home. Matzo. J. S.1) Explore his past feelings of self-worth. She is pale. 150-155. 156. H. M. p. His past is not the most important concern. The nurse asks the student nurse to take Ms. S. C. R. 534.V. Rationale: This will not deal with his immediate need. & Wood. Toronto: Elsevier. J. Bryson’s vital signs while she calls the physician. The immediate physical exam for a client with an upper GI bleed must include an emphasis on blood pressure and pulse. and take measures to assess the risk of suicide. Rationale: The nurse should recognize the client is acutely depressed. 53 Question 53 Jessica Thorton. R. What should the nurse do? 1) Place the client in Trendelenburg position. Contemporary psychiatric-mental health nursing. I am required to tell your parents.” Rationale: This is a false statement. M. I will keep your confidence. Rationale: Although this may assess his adaptation. 4) Explore his perceived adequacy of supports. Jessica asks. Ross-Kerr. Rationale: The RN needs to be accountable for the previous decision of delegating VS to the student nurse. Gerontologic palliative care nursing. p. L. p. M. The RN should verify. Bryson. (2004).” Rationale: Jurisdictions in Canada have mandatory reporting legislation for named communicable diseases. M. (2006). has just been diagnosed with chlamydia. Heitkemper. 2) “Because of your age. D. S. . E. Rationale: The client is feeling helpless and hopeless now. 52 Question 52 Ms. Toronto: Mosby. & Dirksen. 15 years old. Rationale: The vomiting may cause airway difficulties if the client’s head is down. 1030. it does not assess his feelings 2) *3) Ask him if he is having suicidal thoughts. References: Kneisl. On returning to the client’s room.

221-222. Lane’s anxiety. 54 Question 54 Mrs. & Johnstone. A. S. A. Medical-surgical nursing. 58. the nurse has made arrangements with Mrs. p. J. 2) Ask her son to come back after the enema has been administered. 56 Question 56 The nurse arrives at work and discovers that there is a staff shortage for the shift. Toronto: Jones & Bartlett. K. p. What should the nurse do about administering the enema? 1) Ask Mrs.” Rationale: This statement implies that the nurse may have the option to keep the diagnosis confidential. Lane to administer the enema after visiting hours around 2030 hours. . 55 Question 55 Which of the following contributing factors results in the highest death rates of adults in Canada? *1) Smoking Rationale: Tobacco is a risk factor for 25 diseases and accounts for approximately 15% of deaths from all causes. J. 276. References: Black. 66 years old. Lane. Ethics in nursing practice. The nurse is assigned to 4 postoperative and 3 preoperative orthopedic clients. MA: Blackwell. G. H.4) “I am not allowed to make any promises about keeping your diagnosis confidential. (2005). 25.J. (2006). Rationale: There is no reason for the son not to visit. 2) Automobile accidents Rationale: Incorrect Alcohol consumption Rationale: Incorrect Obesity Rationale: Incorrect 3) 4) References: Ross-Kerr. J. & Janes. Lane’s son to leave because visiting hours are over. & Potter. C. 1129. Toronto: Elsevier. Toronto: Elsevier. Rationale: There is no specific time to administer the enema. (2006). Lane’s son. In addition. Code of ethics for registered nurses. Toronto: Elsevier.14. Malden. Also following the enema. & Hawks. Mrs. There are several intravenous medications to give and 2 clients have Type 1 diabetes (insulin dependent diabetes mellitus). p. M. Essentials of community-based nursing. several dressings require changing and staples need to be removed. Fry. M. S. Lane will need to use the washroom. P. 4) Try to postpone the diagnostic test. Perry. M . Leaving may increase Mrs. Clinical nursing skills and techniques. Canadian fundamentals of nursing. Ottawa: CNA. *3) Delay the administration of the enema. whom she has not seen for 2 years. is to receive an enema in preparation for a diagnostic test. References: Canadian Nurses Association (2002). according to the WHO. & Wood. T. The next morning. p. Mrs. Lundy. J. She notes that nursing students are assigned to the unit today. (2003). S. arrives at 2020 hours. p. The enema can be done following the visit. Rationale: There is no specific time for the enema. Rationale: There is no reason to do this at this time. p. (2002).

Sagan and obtains an analgesic. This action does not solve the reason for the alarm.” Rationale: This is not a decision for the nurse to make independently. References: Canadian Nurses Association (2002). p. Ross-Kerr. Rationale: The nurse has other tasks that require her expertise at this time.In evaluating this situation. Canadian fundamentals of nursing. J. 152-153. Ross-Kerr. Sagan. 156. Jonas. 4) Attend to the alarm first. p. which of the following actions should the nurse take? 1) Leave the dressing changes for the next shift of staff. Rationale: Nurse managers intervene to minimize the present danger when client safety is threatened due to inadequate resources. 2) “That is perhaps the best choice. & Hawks. J. She needs to discuss this with the health care team. Sagan later. The unit manager needs to be informed of a potentially unsafe situation regarding understaffing. 2) Offer to assign the preoperative teaching to a student nurse. 2) Reposition and obtain an analgesic for Mr. After discussing this decision with Mr. 9-10. Toronto: Elsevier. Toronto: Elsevier. (2005). Rationale: Students are supernumerary and are not counted on for service. 57 Question 57 The nurse is attending to Mr. J. Medical-surgical nursing. 83 years old. (2006). (2006). & Wood. 4) Reprioritize nursing care to manage the workload effectively. p. J. and then attend to the alarm. Jonas. M. Rationale: This delays client comfort and does not make effective use of available resources. The health care aide enters the room to let the nurse know that another client’s infusion pump’s alarm is ringing. References: Black. Ottawa: CNA. Toronto: Elsevier.” . H. & Wood. Rationale: This is appropriate delegation that frees the nurse to attend to the other tasks at hand. Rationale: Reprioritizing nursing care is not the first action the nurse should take. Rationale: Manipulating infusion pumps is not part of the health care aide’s responsibilities. while the nurse repositions Mr. Sagan. because it’s important to live in peace. p. M. J. 16-17. C. *3) Tell the health care aide to obtain assistance to reposition Mr. J. M. *3) Report the situation to the unit manager. What is the most appropriate nursing action? 1) Tell the health care aide to shut off the alarm. *3) “I will let the other members of the healthcare team know of your decision.152. 58 Question 58 Mr. The client is requesting an analgesic and repositioning. C. which one of the following replies by the nurse shows that she is fulfilling her responsibility? 1) “I will notify the physician immediately so he can stop the treatment. Canadian fundamentals of nursing. Code of ethics for registered nurses. a postoperative client. while the nurse attends to the alarm and obtains an analgesic.” Rationale: This is not a decision that the physician makes independently. tells the nurse that he is refusing radiation therapy treatment because he wants to die in peace. and return to obtain an analgesic and to reposition Mr. Sagan with the help of the health care aide. Rationale: Nurses have responsibilities and accountabilities for their client assignments.

Rationale: As the nurse was not able to resolve the problem with the aides – she must report it to the supervisor. p. References: Ross-Kerr. M. & Johnstone. p. 2) Chart that clients are not being turned every 2 hours. MA: Blackwell. tomato juice Rationale: Does not include milk products. p. References: Matzo. L.. 3) 4) References: Canadian Nurses Association (2002). (2006).. (2002). 16-17. 2% milk Rationale: Does not include meat and alternatives. (2004). Explain to the aides the consequences of their actions. The day shift may not be able to do anything. 61 Question 61 Jeffrey. . Fry. Gerontologic palliative nursing care. fruit salad. Ross-Kerr. He has been receiving an elixir of acetaminophen (Tylenol) and codeine po. & Snyder. M . His mother states that the prescribed analgesic is not effective in managing her infant’s pain. 2) Chicken sandwich.” What should the nurse do? *1) Inform the aides that the situation will be reported to the immediate supervisor. The nurse notices on the night shift that the clients are not being turned every 2 hours as scheduled on the night shift because the 2 aides sleep. and milk products. Toronto: Elsevier. T. Ethics in nursing practice. roll and butter. 3) *4) Peanut butter sandwich. J. spinach salad.Rationale: This is an ethical decision and should involve the health care team. Berman. p. Erb. Canadian fundamentals of nursing. D. 1285. they reply. M.J. S. medium apple. cranberry juice Rationale: Does not include grain or milk products. 4) “You can refuse your treatment today and we’ll talk about it again tomorrow. C. as ordered. Toronto: Prentice Hall. grain products. vegetables and fruits. 85. C. Code of ethics for registered nurses. Toronto: Mosby. Mushroom omelette. (2004). W. q. S. Malden. & Wood.4h. 59 Question 59 A new nurse is in charge of a long-term care unit for elderly clients. p. 984. (2006). G. B. The nurse can be an advocate for the client at the meeting. 107-108. Fundamentals of nursing. skim milk Rationale: Contains all 4 food groups: meat and alternatives.J. 60 Question 60 Which lunch menu includes all food groups from Canada’s Food Guide? 1) Green salad. A.” Rationale: This is not an option that is either ethical or medically sound. Ottawa: CNA. When the nurse talks to them about it. & Wood. 98-103. Kozier. 9-10. J. Report the situation and her discussion with the aides to the day team. 6 months old. is 12 hours postoperative following correction of bilateral clubfeet and subsequent casting. J. p. & Sherman. Rationale: This can be done – but based on the aides response will not resolve the issue. Rationale: This does not resolve the problem and the nurse has an ethical responsibility to report unsafe care. Rationale: The report needs to go to the supervisor who can resolve the situation. orange. “Just look after your pills. J. we have more experience than you. Toronto: Elsevier. Canadian fundamentals of nursing. M.

1246. p. 3) 4) References: McKinney. Murray. E. *3) Keep existing bag upright before closing the clamp. Rationale: Parents know their children best and are sensitive to changes in their behavior. There is no reason that a child should have to experience post-operative pain. This child’s analgesic order may not be adequate to effectively manage his post-operative pain. 1162.. Rationale: Parents know their children best. but may not be effective in controlling severe post-operative pain. Philadelphia: Lippincott Williams & Wilkins. what action should the nurse take? 1) Allow existing solution to clear the drip chamber. Philadelphia: Lippincott Williams & Wilkins. (2005). E. p. 4) Remove spike from existing bag prior to removing protective cover from new bag. Pillitteri. Murray.. Toronto: Elsevier. (2007) Maternal & child health nursing. Maternal & child health nursing. Total pain relief should be the goal. S.. A.What action would be most appropriate for a nurse to take at this time? 1) Tell the mother that Jeffrey’s discomfort stems from physical restraint of the casts and not from pain. Rationale: Distraction is one non-pharmacologic strategy for managing pain. Rationale: Fluid should be left in chamber to provide fluid to vein when bag is changed and prevent air from entering tubing. (2007). 62 Question 62 Which method would be appropriate when screening a class of Grade 1 children at high risk for exposure to tuberculosis? *1) Skin test Rationale: This is the recommended testing. S. J. Pillitteri. 3) *4) Verify the mother’s findings and contact the surgeon to request a change in the analgesic order. Austin. 2) Tell the mother that it is to be expected that children will experience some pain following surgery. This may be useful for a period of time. & Ashwill. Rationale: This response does not address the mother’s concern. .. S. 2) Sputum test Rationale: Young children can not cough deeply enough to produce a sputum sample. In order to safely change to a new bag of intravenous fluid.Yew. S. Suggest to the mother that she try and distract Jeffrey by sitting in the rocking chair and singing to him. Maternal-child nursing. A. 68 years old. calls the nurse to report that her intravenous bag is nearly empty. p. & Ashwill. S. Toronto: Elsevier. (2005). Austin. 994. 63 Question 63 Mrs. James. S. p. J. Respiratory assessment Rationale: Inaccurate and inconclusive. This response shows a lack of respect for the mother’s judgement. It would be done as a follow-up to a positive skin test. Maternal-child nursing. Rationale: This prevents air from getting into the tubing. 2) Open roller clamp prior to spiking new bag. References: McKinney. James. Rationale: The clamp should be closed to prevent air from entering the system. 1268. Radiographic examination Rationale: This is not a routine screening test.

p. & Ashwill. He comes to the nursing desk with a stiff neck deviating to one side. His arms and legs are stiff and he appears to be short of breath. G. It can progress to laryngopharyngeal constriction with respiratory impairment. A. p. 250. (2006).. especially of the head and neck. Nursing process and critical thinking. p. G. 149-154. It requires immediate action by the nurse which is . M. smooth change over and increase the chances of contaminating spike. 66 Question 66 A 38-year-old male client with a diagnosis of paranoid schizophrenia is being treated with the neuroleptic medication olanzapine (Zyprexa). p. 64 Question 64 Which one of the following must guide the nurse when providing nursing care? 1) Medical orders Rationale: The nurse needs to ensure that medical orders are completed but they do not guide the nurse in planning her care. 4) The nurse’s skills based on the health situation Rationale: The client is the focus of care – not the nurse’s needs. 1343. W. 943. Toronto: Elsevier. Stuart. Toronto: Elsevier. Berman. Clinical nursing skills & techniques. S. (2005). 4) “I guess sometimes God works in mysterious ways. Kozier. A. *3) Client needs Rationale: Nursing care should be client centered. Toronto: Elsevier.” Rationale: True. Ross-Kerr. Murray. but not helpful. 2) The priorities determined by the nurse Rationale: Priorities are determined with the client and not only by the nurse. you’re not in this alone. References: Perry. & Snyder. J. Which of the following prescribed prn medications should the nurse administer? *1) Benzotropine mesylate (Cogentin) I. Which response by the nurse would be the most supportive? 1) “Would you like to take a break from all this and go to the teen room?” Rationale: May cut off discussion. 65 Question 65 Joey. Maternal-child nursing. Fundamentals of nursing.” Rationale: May explain death for the nurse. & Potter. G.M. *3) “This must be hard for you. James. but can be little comfort to a person who does not envision it to be true. 12. Toronto: Prentice Hall. C. & Laraia. All of us are dying. 12 years. Principles and practice of psychiatric nursing. References: McKinney. (2006). (2005). M. T. 819. Canadian fundamentals of nursing. an enlarged tongue sticking out of his mouth and he is drooling. References: Wilkinson. Toronto: Prentice Hall. p. “All of us” are not dying right now. Toronto: Elsevier. Rationale: Dystonia is characterized by involuntary muscle spasm. P. 2) “Joey. J.Rationale: Does not permit quick. 1394-1396. S.820. E. M. & Wood. (2004). J. (2001). B.” Rationale: Acknowledges Joey’s condition. has terminal cancer. J. Erb.... S. A. p. S. He has been melancholic all day. J.

Rationale: The client would not be able to swallow the tablet.r. Deglin J. 4) References: Smeltzer. B. Olanzapine (Zyprexa) SL Rationale: Giving an antipsychotic would exacerbate the condition as extrapyramidal effects and dystonic reactions are side effects. Philadelphia. Also.o. 2) Give the medication and leave a request on the chart for a change in orders. A. F. PA: Lippincott. Benzotropine mesylate (Cogentin) is the only anti-cholinergic medication available which can be given by injection.n. 313-314. Williams & Wilkins.administering the anticholinergic medication by injection. 57 years old. “Clients who have this test need to be kept overnight to watch for complications. Rationale: Incorrect: The doctor may not see this message for several hours and the client would not receive any pain relief during this time.. The client needs an analgesic that would be effective sooner. the x-ray would require staying for observation. G (2004).year-old skier. is scheduled for a left femoral arteriogram. (2005). A manual of laboratory and diagnostic tests. Psychiatric nursing for Canadian practice. Davis. This action would not be addressing the client’s needs as Tylenol would take more time to be effective. Philadelphia: Lippincott Williams & Wilkins. q 4h. What else did the physician tell you about this test?” Rationale: The nurse is assessing the client’s knowledge and providing information. p. a 28. Lee. H. & Vallerand.R. Lorazepam (Ativan) I. 67 Question 67 Mrs. 3) 4) References: Austin. Davis’s Drug Guide for Nurses. (2004). Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed).” Rationale: This is blaming. following an open reduction of a fractured femur. *2) “This procedure is more than just an x-ray.) Philadelphia: F. What action should the nurse take? 1) Give the medication and inform the client of the physician’s order. Lippincott-Raven.M. She states. Fischbach.” Rationale: Incorrect. 3) “With this type of x-ray..” Rationale: Inaccurate information. & Boyd M. 192-193. C. A. The nurse is not providing the client with further information. has been ordered. Acetaminaphen (Tylenol) 1 g. the nurse is not accurately responding to the client’s question. . p. Using the word complications may frighten the client. PA.. W. & Bare. Will I be able to go home right after?” How should the nurse respond? 1) “Your physician should have explained the test. Rationale: Incorrect: The client has just returned from the OR and would need an analgesic that would have a more immediate action.o. He is experiencing post-op pain. p. p. clients are allowed to go home right away. A. (9th ed. A tablet would not act quickly enough to relieve the client’s serious symptoms. It’s more involved than just an x-ray. S. has just returned from the O. 68 Question 68 Peter. and not exploring what she has been told. Rationale: The symptoms are characteristic of a dystonic reaction rather than anxiety. 2) Trihexphenidyl (Artane) p. H. “The physican told me I have to have an x-ray of my leg. (1998).

H. Porter’s pain? *1) Alleviation is usually optimal when the person can use a patient controlled analgesic pump. Deglin. M. 69 Question 69 The nurse is responsible for planning weekly interdisciplinary team meetings. 70 Question 70 Mr. Rationale: Incorrect: Assumes that the time is inconvenient. (2005). A. St. p. This assumes the Dr. Canadian fundamentals of nursing. References: Austin. Parenteral medications are the most effective in relieving post-op pain. while this oral analgesic takes more time to be effective. & Boyd. A. References: Potter. Beebe. 2) Remind him of his responsibility to collaborate with team members. Rationale: Incorrect: This action would not be addressing the client’s needs.) Philadelphia. This may not be the problem. Tylenol is effective with mild pain and would not be effective for immediate post-op pain of a fractured femur. This allows the opportunity to understand the cause. Rationale: Correct: First step in exploring the problem. Assumes that the physician is key to the meetings. Philadelphia: Lippincott Williams & Wilkins.. Rationale: Correct: When the client has control over pain this can help minimize the pain. 86-87. (1998). V..W. Rationale: Incorrect: Codeine is not as effective in alleviating cancer pain. & Vallerand. 67 years old. Interpersonal communication: Relating to others (3rd ed. Davis’s drug guide for nurses (9th ed. F. & Perry. Redmond. J. Porter. Codeine is particularly effective in alleviating cancer pain. S.). H. 4) Offer to reschedule meetings at a more convenient time. P. *3) Discuss with him the reasons for not attending scheduled meetings. has prostate cancer with bone metastases. How should the nurse respond? 1) Meet with him separately to discuss issues related to clients’ care. Porter’s pain is not being relieved and needs something that will relieve his excruciating pain. A. Cooper rarely attends.. Toronto: Pearson Education Canada. (2006). Beebe. He says that he is in excruciating pain. 4) Give the medication and assess effect of the analgesic. A. 10-11. p. Porter. Davis. Rationale: Correct: This action would be most appropriate in addressing the client’s needs. S. Rationale: Incorrect: Avoiding the problem would not solve the issue of absence. She has observed that Dr. Rationale: Incorrect: Confrontation would not explore the issue. This type of medication achieves pain control more quickly than nurse administered intermittent doses. Louis: Mosby. A. 6-8. Cooper is intentionally missing the meetings. even though he is present on the unit. (2004). K. The analgesic doses must be spaced out as much as possible to prevent tolerance in Mr. Porter’s pain. M. What should the nurse know about use of pharmaceutical agents to manage Mr. 256–267. p.*3) Call the physician and request a change in analgesia. Psychiatric nursing for Canadian practice. A. 2) Administering analgesics every 4 hours is sufficient to alleviate Mr. which has not been alleviated. Rationale: Incorrect: This is not an effective way of relieving pain. and may reinforce missing interdisciplinary team meetings is acceptable. M. Morphine slow release or hydromorphone 3) 4) . Rationale: Incorrect: Mr. Analgesic need to be given on routine basis and as the client requires to relieve pain. G. & Geerinck T.

(2006). Infants cannot do more that grasp objects at this age.) Philadelphia. Code of ethics for registered nurses. Mitchell. M. *2) Remove drapery cords that may dangle close to the crib. Human development: A lifespan view (2nd ed. Rationale: Incorrect: Nurses must safeguard the trust of clients. & Wood. C. An infant at this age may not be crawling let alone opening cupboards.. Davis. 19 years old. A. References: Ross-Kerr. arrives at the hospital having been beaten and sexually assaulted. Davis’s drug guide for nurses (9th ed. 3) Have prescriptions dispensed in containers with childproof caps. Rationale: Correct: Nurses disclose confidential information only as authorized by the client unless there is a legal obligation to disclose. Motor development for an infant at this stage would be sitting on a lap and grasp objects.(dilaudid) is effective in alleviating cancer pain. it is not relevant for infants. V. Toronto: Elsevier. C. Canadian Nurses Association (2002). Community health nursing: Theory and practice (2nd ed. & Wood. J. (2000). Ottawa: CNA.). p. 2) Tell the police to return after the assessment has been completed. p. 72 Question 72 Which of the following statements should the nurse include when teaching parents of a 5-month-old infant about child safety? 1) Ensure that electrical outlets are covered or plugged. 4) References: Kail. A. 99. Physicians have a similar duty to maintain confidentiality in this situation. p. 606-607. Rationale: Incorrect: Nurses disclose confidential information only as authorized by the client unless there is a legal obligation to disclose. Information learned in the context of a professional relationship should be shared only with the client’s permission or as legally required. (2000). Motor development for a 5 month old would be to grasp objects. R. Rationale: Incorrect: This is more of a consideration in toddlers. & Cavanaugh. Rationale: Incorrect: This is more of a consideration in toddlers. C. . Deglin. H. Install safety latches on cabinets that contain cleaning products.).) Philadelphia: Saunder. J. Canadian fundamentals of nursing (3rd ed.. M. F. (2006) Canadian fundamentals of nursing (3rd ed. H. She shares with the nurse that the perpetrator of the assault was her boyfriend. What should the nurse do? 1) Disclose the identity of the perpetrator to the police. p. J. & Maurer. M. Smith. A. J. Toronto: Elsevier. *3) Ask the client if she would like to speak to the police.). J. 116. Rationale: Incorrect: Although this is an important safety consideration. J. Scarborough: Nelson/Thomson Learning. 1245.. C. Rationale: Incorrect: This information is confidential and will still be confidential upon completion of the client’s assessment. There is no legal obligation to disclose here. The police arrive at the hospital and ask the nurse for information regarding the identity of the perpetrator. 4) Direct the police to the client’s room. F. p. References: Ross-Kerr. & Vallerand. (2005). 71 Question 71 Ms. 760761. Rationale: Correct: Infants may be able to reach drapery cords and could strangle themselves.

). Even if a procedure is against the nurse’s personal values the nurse is responsible to care for the client. ON: Prentice Hall. Pediatric Nursing: Caring for children (3rd ed. and acquire new skills and knowledge in their area of practice. 74 Question 74 Mrs. Rationale: Correct: According to the Code of Ethics the nurse must practice within their own level of competence. They typically complain about an overwhelming workload. *3) Use a doll to help explain the procedure to Amy. *3) The nurse must not perform any act outside the nurse’s level of competence. (2003). The nurse has raised the issue with faculty but has seen no changes. The physician asks the nurse who is a recent graduate to defibrillate Mrs. (1999). p. The nurse must practice within their own level of competence. Rationale: Incorrect: Amy will not understand what the procedure is about. Since this is not a skill that the new graduate would have upon completion of a nursing program it is appropriate for the nurse to refuse. Rationale: Incorrect: This is not appropriate for a client of this age.73 Question 73 Amy Carter. student nurses have come to the campus health nurse with disturbing levels of stress. 4 years old. . Du Gas.. Code of ethics for registered nurses. Maternal & child health nursing: Care of the childbearing and childrearing family. References: Ball. Amy will not understand what the models are all about. & Bindler. E. Nurses must give primary consideration to the welfare of clients. 4) Show Amy a model of the heart and explain how the catheter is inserted. Poole? 1) The nurse wishes to comply with the wishes of Mrs. Teaching is enhanced by meeting the child’s developmental needs. 1274. Williams & Wilkins. B. Rationale: Incorrect: Having a colleague guide the nurse is not acceptable. S. Rationale: Incorrect: Showing the equipment to a pre-schooler is not appropriate. Ottawa: CNA. Why is the nurse justified in refusing to defibrillate Mrs. 4) A colleague who is very familiar with defibrillation must guide the nurse in the technique. 7378. R. 2) Give Amy a tour of the procedure room and let her handle the equipment to be used. 75 Question 75 For several years. Pilliterri A. is scheduled for a cardiac catheterization. W. W. Rationale: Incorrect: The graduate nurse has not been taught this skill or certified in it. J. A doll is something that the child can relate to.). Rationale: Incorrect: Same answer as 1. References: Canadian Nurses Association (2002). Philadelphia: Lippincott. Poole. Upper Saddle River. & Ronaldson. 1048. Pre-schoolers have limitations in thought. (2007). NJ: Prentice Hall. 2) Cardiac defibrillation goes against the nurse’s personal values. Rationale: Correct: Using a doll can help the child visualize the procedure. goes into cardiac arrest. p.. The code of ethics states the nurse base their practice on relevant knowledge. L. According to the code of ethics the nurse must practice within their own level of competence. Esson. Scarborough. p. 66 years old. Nursing foundations: A Canadian perspective (2nd ed. 1228. Poole. Poole’s spouse who does not want her resuscitated. What should the nurse do to prepare Amy for the procedure? 1) Describe the procedure to Amy and her parents. It is more important to familiarize Amy to what will happen with the aid of a prop or visual aids.

Psychiatric nursing for Canadian practice. (2000). (2005). This response reinforces that the students cannot manage their workload. Ask the opinion of the health care team members. L. 77 Question 77 When teaching a parent from a specific ethnic background about family nutrition. Louis: Mosby. Rationale: Correct: The nurse needs to conduct a self-assessment to determine what other actions she should take next. Rationale: Incorrect: Inappropriate response. Rationale: Incorrect: This assumes prior judgment of their dietary practices. Set up an after-hours class to teach them relaxation techniques. & Leahy. This may reinforce to the students that they cannot manage their workload and does not support the students claim. 3) *4) Work with students to lobby nursing faculty for changes in student workload. G. Nurses and families: A guide to family assessment and intervention (3rd ed. Philadelphia: Lippincott Williams & Wilkins. The client may feel that they will not be cared for as well if there opinion of the nurse’s care is not optimal. Davis. M. M. 2) Bring the problem to the attention of the student body and faculty again. A self assessment needs to be done prior to the nurse verifying her perceptions with a supervisor. p. what is the most appropriate nursing action? 1) Discuss the possible need to alter traditional cooking practices. However.What should the nurse do? 1) Work with the students to assist them with time management skills. 3) 4) References: Austin. What should she do as a first step? *1) Conduct a self-assessment. Rationale: Incorrect: Inappropriate response. Question the clients for whom she is responsible. The student may have excellent time management skills. It does not allow for respect of cultural specific practices. 101 Stuart. but the workload is the problem. Rationale: Incorrect: This imposes upon the client. Rationale: Correct answer: There is evidence in the literature that student nurses have the highest levels of stress when compared with students in other health professions. Rationale: Incorrect: This is not the first step. (1998). 2) Reassure the parent that foods in Canada are of a high standard. & Boyd.) Philadelphia: F. St. Rationale: Incorrect: Not the best answer. 2) Validate her perceptions with her immediate supervisor. Rationale: Incorrect: The health care team members may not be able to accurately give an evaluation of the nurse’s performance. It infers that the parents’ choice of following traditional cooking .A. it is important to validate to decrease bias. 76 Question 76 The nurse wants to evaluate her performance as a caregiver. This is the initial step in self awareness. References: Wright. & Laraia. The nurse may be creating an undue influence. T. 320. p. Principles and practice of psychiatric nursing. 17. Rationale: Incorrect: This is not consistently accurate. A. W. M. M. The campus health nurse has tried this already. This is not helping to get to the cause of the stress as it is the workload that is a problem. It does not incorporate client choice. It is time to lobby for change because there has been no action and the problem persists. W.

How will the nurse best gain support for this program? 1) Write a letter to all the students of the school inviting them to participate in the program. *3) Make an appointment with the school principal and parent council to discuss a safety patrol program. but he states that he has been having increasing dyspnea on exertion which has now progressed to difficulty breathing while at rest.) St. Also.B. “Did you recently receive the flu vaccine?” Rationale: Incorrect: These are not the presenting side effects of the flu vaccine. M. He does not have a cough or sputum production. Rationale: Incorrect: This would not be the initial step in promoting this program and not all students would be of an appropriate age to act as school patrols. Which one of the following questions would be appropriate for the nurse to ask based on these findings? *1) “Do you have a family history of emphysema?” Rationale: Correct: These are the characteristic presenting symptoms of a client with emphysema and this condition has a familial predisposition. Psychiatric nursing: Contemporary practice. 447. (2004). p. fatigue. 2) Collect data on the traffic patterns in the community and submit the findings to the local health department. p. 278. Rationale: Correct: Asking for client input shows respect and helps assess if there is a need for teaching. night sweats. C.453. p. M. (2002). J. CN: Appleton & Lange. Clinical manifestations of TB include cough. p. C. Boyd. A. Further subjective questions need to be asked to gather a complete health history. 78 Question 78 A 65-year-old male client arrives at the local clinic. *3) Ask the parent about the family’s nutritional preferences. Smeltzer. Philadelphia: Lippincott. This shows value of client choice. 3) 4) References: Jarvis. Rationale: Incorrect: This strategy may provide supportive data for a trend that has been observed but the data should be directed to the school not the health department. (1996). (2000). He has an increased anterior-posterior chest diameter. On examination.) Philadelphia. Louis. Rationale: Incorrect: It is directive and an unnecessarily long time. B G. PA: Lippincott. The nurse would like to see changes at the school. these symptoms are respiratory in nature and further questioning is needed. decreased breath sounds.practices is not appropriate. S. & Bare. References: Clark. Rationale: Correct: Addressing key stakeholders and leaders in the school would inform them of the health risk and . and decreased oxygen saturation. Nursing in the community (2nd ed. Saunders. 4) Tell the parent to document the family’s dietary habits for one week. MO: W. “Have you recently been in contact with a person with Tuberculosis?” Rationale: Incorrect: These are not the findings of TB. 2) “Have you ever had any teaching on normal respiratory changes with aging?” Rationale: Incorrect: These symptoms are not normal changes associated with aging. Brunner & Suddarth’s textbook of medical-surgical nursing (9th ed. Physical Examination and Health Assessment (4th ed. 278. his colour is pink.) Stamford. weight loss. 79 Question 79 The nurse at an elementary school has observed a trend of pedestrian-vehicle accidents and wishes to promote a school safety patrol program.

References: Canadian Nurses Association (2002). Rationale: Correct: Mentally competent adults have the right to refuse treatment. Rationale: Incorrect: This is coercive. Rationale: Incorrect: Mr. . 4) References: Kemp. Which of the following nursing actions is most appropriate? 1) Contact the physician to order an oral antiemetic. During a biweekly visit. Smeltzer. C. Scott to a treatment facility. Scott has the right to choose whether he wishes to seek treatment or not.E. Scott some coffee and a sandwich if he will agree to go for treatment. P. (2000).B. Rationale: Incorrect: Adequate hydration is appropriate. Encourage adequate hydration by adding more fruit juices. Toronto: W. Identification of cause is important. C. E. Community nursing: Promoting Canadians’ health. but nonacidic juices should be used rather than those which are acidic. J. *2) Sit with the client and assist in identifying triggers. Schubert. B. S.) Philadelphia: Lippincott. New York: Thomson Delmar Learning. Scott’s mental status to make sure that he is able to understand the need for treatment. 2) Contact the community police and request that they escort Mr. Saunders. Hitchcock. Philadelphia: Lippincott. 184-185. The client may not be absorbing the medication. Community health nursing: Caring in action. the nurse finds that the client has begun to experience occasional nausea and retching. M. Offer to buy Mr. Ottawa: CNA. Scott refuses? 1) Speak with Mr. Rationale: Incorrect: This may involve a breach of confidentiality and the nurse should not be discussing his health needs without his permission. Rationale: Correct: The treatment of nausea and vomiting is based on the cause. 81 Question 81 Mr. 3) *4) Assess Mr. A. J. Brunner and Suddarth’s textbook of medical surgical nursing. Rationale: Incorrect: An oral antiemetic would not be effective in this case as the client has nausea and retching. 80 Question 80 A client is receiving palliative care at home. 285-286. Scott’s homeless friends and ask them to encourage him to seek treatment. (2003). The nurse notes a large infected ulcer over his left lower leg and suggests he go to the nearest treatment facility. & Bare. Rationale: Incorrect: This is a top down approach that does not allow community involvement. There is a fine line between encouragement and bribery. Nurses must support informed decision-making. (1999). p. (2004). but with head elevated. The community health nurse finds him huddled in a doorway shaking. What should the nurse do when Mr. Code of ethics for registered nurses. 3) Recommend that the client rest an hour after each meal in side-lying position. References: Stewart. Rationale: Incorrect: Resting after meals is suggested. Scott is a 37-year-old homeless person. This is not a matter for the police. G. S. Terminal illness: A guide to nursing care (2nd ed.. p. 4) Submit a proposal to the school board requesting that a safety patrol program be mandated. Keeping a journal will assist in identifying the cause. & Thomas. The fluids may be one of the causes of the nausea.assist them in understanding the benefits of a safety program.

M & Smith. K.) Upper Saddle River. At 2 days post operative for orthopedic surgery it is unlikely that the client does not need pharmacological intervention for pain. Ethical and legal issues in Canadian nursing. Rationale: Incorrect: Giving an unordered dosage of medication without prescribing authority would be outside the nurse’s scope of practice. This does not explore other options with Mrs. 83 Question 83 Mr. W. Saunders. (1998). Davis to remain at home while Mrs.Keatings. Bergon F. A. I. Davis possible options for respite care. What should the nurse base her action on? 1) It is appropriate to give a lower dosage of analgesic than ordered. 89. Rationale: Incorrect: It is normal to need narcotic intervention up to at least 72 hours postoperative following orthopedic surgery.) New York: Lippincott. is a palliative client who has requested that he be allowed to die at home. Nichols L. 3) *4) Discuss with Mrs. (1996). p. Rationale: Correct: Respite care provides time away from the client for the caregiver and helps relieve care-giver burnout. Louis: Mosby. 82 Question 82 Ms. 481-485. 84 Question 84 . Also. Davis. P. She just wants a reduced dosage. 73 years old. M. p. Ms. D. Clinical pharmacology and nursing management (5th ed. Rationale: Incorrect: This provides only a temporary solution to the wife’s concerns. and does not look at other possible alternative. NJ: Prentice Hall. J. p. Toronto: Jones and Bartlett Publishers. Davis that would provide support while Mr. (2000). Benoit may feel that she does not need the same strength of analgesic as before. O. Davis for a few hours while Mrs. Davis being admitted to the hospital. (2006). This would allow Mr. Medical-surgical nursing: Critical thinking in client care (3rd ed. Davis involve her family with her husband’s care.. 61-71. Lemone. (2003). Benoit recognizes that she needs an analgesic. She requests acetaminophen (Tylenol) plain instead of her ordered dosage of acetaminophen with codeine 30 mg (Tylenol 3). 3) At this level of pain. *2) Ms. Davis is at home. Davis tells the home care nurse that she is tired. W. Benoit is recovering from orthopaedic surgery 3 days ago. Rationale: Incorrect: This is a subjective decision that should only be made with the client. What course of action should the nurse take? 1) Offer to stay with Mr. & Burke.. This may be too forceful as the family may be unable or unwilling to help. 2) Discuss with her the necessity of Mr. and does not know how much longer she can cope with the responsibility of providing total care for her husband. Rationale: Incorrect: This would go against the client’s wishes. non-pharmacological interventions will be sufficient. Davis has some rest. St. M. Davis rests. Toronto: W. M. Rationale: Correct: The prescriber should be the person to adjust the pharmacological pain relief regimen. Suggest that Mrs.. References: Lubkin. B. Mrs. Benoit’s request to have her analgesic reduced indicates concern about addiction. Chronic illness: Impact and interventions. Rationale: Incorrect: The family should be encouraged to provide assistance. Cookfair. B. Larsen. Benoit should have her pain medication re-evaluated by her doctor. 4) References: Eisenhauer L. Nursing care in the community. P. Ms. Ms.

” He sits on the bed and looks at the wall. 503. M K. Rationale: Correct: Pinkeye is bacterial conjunctivitis spread by direct contact. 2) Sterilize all visibly soiled toys at the end of each day. Control of communicable diseases manual (18th ed. Rationale: Incorrect: Sterilization is the complete elimination of all microorganisms. St. A (1995). She is unable to find a written agency policy. protocol or procedure. She is the only RN on duty and is unsure about how to handle the situation. A. C. Kerr. Smith. Esson. Also. B. assumes that the microorganisms are visible. Contaminated hands are a prime source of cross-infection. Saunders Company. says. W. 124-126. E. 106.. 659. (2nd ed. The most important technique in preventing and controlling the transmission of infection is handwashing. Canadian fundamentals for nursing. Which of the following would best guide her decision-making? 1) The client’s wishes Rationale: Incorrect: The client’s wishes may conflict with professional practice standards or with agency policy. Rationale: Incorrect: A good health promotion idea. Michel. refusing to speak. L. L. “I don’t want any needles. C. p. Leave me alone. 86 Question 86 Michel. D. 15 years old. *3) Increase the frequency of handwashing by staff and children. F. & Sirotnik. or may not have correct information.) Washington. MI: MosbyYear Book. Philadelphia: W.. who is accompanied by his mother. Ventilation is not relevant to decrease incidence of pinkeye as this is spread through contact. p. J. (1997). Nursing foundations: A Canadian perspective.B. G. (1999). p. References: Du Gas. Ronaldson. 218. Perry. *3) Professional standards of practice Rationale: Correct: Standards of practice provide objective criteria for nurses to provide care. While it is a good idea to routinely clean or disinfect toys and surface areas. DC: American Public Health Association. p. it is not necessary nor possible to sterilize them within a daycare centre. S. Rationale: Incorrect: Important in preventing the spread of airborne pathogens. (2004)..) Scarborough: Prentice Hall. M. is being admitted to the hospital with a new diagnosis of diabetes (Type 1). References: Heymann. 85 Question 85 What is the best advice a nurse can give to a day-care supervisor who wishes to decrease the incidence of bacterial conjunctivitis (pink eye)? 1) Improve waste disposal techniques in the classrooms. Potter. 4) Ensure proper ventilation throughout the building. This would not provide information regarding professional standards of practice. 2) Consultation with other night staff Rationale: Incorrect: Other staff may not be professional. .The registered nurse (RN) in charge of a long-term care agency from midnight to 0800 is confronted with a clinical situation concerning a resident. Community health nursing: Theory and practice. P. & Maurer. Louis. A. The nurse needs to refer to her professional practice standards. 4) The client’s health record Rationale: Incorrect: Resource limited to information about client only.. but will not necessarily decrease bacterial cross-contamination between children. He is to receive insulin.

Missouri: Saunders Elsevier. The nurse needs the essential information to proceed with measures to meet his physical needs. Rationale: Incorrect: The nurse must include data from Michel when planning care. & Boggs. Suggest that he watch a video on diabetes. St. p. it does not enhance the therapeutic relationship with the nurse. thighs or buttocks. Louis. Wong’s nursing care of infants and children (8th ed. 942. “I don’t want any needles. Michel. 87 Question 87 Michel.). refusing to speak. Maternal and child nursing: Care of the childbearing and childrearing family (5 th ed. 407. 2) Postpone the assessment until later to give Michel time to adjust to his diagnosis. 149. who is accompanied by his mother. Let Michel express his sullen behaviour and obtain assessment data by referring to his chart. K. Rationale: Incorrect: Although this is appropriate for Michel. is being admitted to the hospital with a new diagnosis of diabetes (Type 1). D. Rationale: Correct: Gives Michel a sense of control that will encourage him to communicate.What should the nurse do to complete the nursing assessment? 1) Respect Michel’s reluctance to participate and complete the assessment with his mother. Leave me alone. Louis. “I don’t want any needles. refusing to speak. What key information about diabetes management should the nurse know? 1) Insulin increases blood sugar after meals by facilitating the absorption and use of glucose.). Rationale: Incorrect: Solitary activity does not enhance the therapeutic relationship with the nurse. Wong’s nursing care of infants and children (8 th ed. D. p. & Wilson. 2) Encourage him to chat with other teenagers with diabetes. The physician prescribes insulin for Michel. E. 88 Question 88 Michel. who is accompanied by his mother. It might take quite some time for him to adjust. (2007). M. Rationale: Incorrect: Insulin decreases blood sugar. 3) 4) References: Arnold. He is to receive insulin. Leave me alone. p. St. 3) *4) Obtain the essential information from his mother and wait until Michel is willing to reply. Rationale: Incorrect: Administration of insulin cannot be postponed. 149. References: Hockenberry. Missouri: Elsevier Mosby. He is to receive insulin.). abdomen. Rationale: Incorrect: It is important to include Michel in data collection. (2007). Williams & Wilkins. Rationale: Incorrect: Insulin is administered before meals. p. & Wilson. M. Rationale: Incorrect: Solitary activity does not enhance the therapeutic relationship with the nurse. 1050. Missouri: Elsevier Mosby. . (2007).” He sits on the bed and looks at the wall.U. is being admitted to the hospital with a new diagnosis of diabetes (Type 1). Michel.) Philadelphia: Lippincott. Hockenberry. 15 years old.” He sits on the bed and looks at the wall. A. Pillitteri. (2007).C. 15 years old. What should the nurse do to facilitate the establishment of a therapeutic relationship with Michel? *1) Invite him to participate in planning his care. says. says. St. Louis. Rationale: Correct: It is important that the nurse obtain information from both Michel and his mother. 2) Insulin is injected subcutaneously after meals in the arm. Interpersonal relationships: Professional communication skills for nurses (5th ed. Leave him alone and give him the opportunity to be alone to talk with his mother.

89 Question 89 Michel. & Wilson. He is to receive insulin. Rationale: Correct: Blood sugar levels fluctuate under these circumstances and insulin dosage may need to be adjusted accordingly.” 4) . St. says. References: Hockenberry. M. (2007). Michel confesses that he occasionally consumes drugs and alcohol. Leave me alone. says. He may feel out of place in a group who perform self care. and changes in physical activity. Michel. “I don’t want any needles. D. *4) Insulin doses may need to be adjusted in cases of illness. p.” He sits on the bed and looks at the wall.). *2) “I must inform the care team. Smeltzer. He is to receive insulin.” Rationale: Incorrect: The nurse has an obligation to document pertinent information on Michel’s chart. 15 years old. & Bare. “I must inform the police. M. is being admitted to the hospital with a new diagnosis of diabetes (Type 1). Missouri: Elsevier Mosby. 1173. He refuses to administer the insulin himself because he says he is afraid to inject himself. Wong’s nursing care of infants and children (8th ed. Pillitteri. 1721. 3) Ask Michel’s mother to administer his insulin. 4) References: Hockenberry. & Wilson. 90 Question 90 Michel. Maternal and child nursing: Care of the childbearing and childrearing family (5th ed. 15 years old. how should the nurse respond? 1) “I won’t note it in the chart. Rationale: Incorrect: Blood sugar levels guide insulin dosage.). S. refusing to speak. (2004). (2007). Michel. What should the nurse do to help Michel overcome his fear? 1) Suggest to Michel that he use only his abdomen as the injection site. Williams & Wilkins. 1715.G. Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed. Given this admission. He subsequently regrets admitting this. who is accompanied by his mother. Wong’s nursing care of infants and children (8th ed. Michel has already received two injections of insulin. since I believe that you are entitled to make your own choices. refusing to speak. Rationale: Incorrect: Does not address overcoming the fear of actually administering the injection. since these substances are illegal. St.1523. p. without his parents’ knowledge. who is accompanied by his mother. Organize a discussion period with other teenagers with diabetes. 3) “I am required to tell your parents because you are a minor. since these substances can have an impact on your diabetes. is being admitted to the hospital with a new diagnosis of diabetes (Type 1).) Philadelphia: Lippincott. B. Louis. Louis.) Philadelphia: Lippincott. Williams & Wilkins. Rationale: Correct: Michel can gain confidence by practicing with the equipment.3) Glucometer readings will determine the quantity of food that Michel must eat at mealtimes. *2) Encourage Michel to handle the items required for the injection. “I don’t want any needles. Rationale: Incorrect: Does not support Michel becoming independent in caring for his diabetes. A. p. (2007). Missouri: Elsevier Mosby.” Rationale: Incorrect: The nurse is obligated to maintain confidentiality. Drug and alcohol use could affect his diabetes.” He sits on the bed and looks at the wall. Rationale: Incorrect: Michel may not wish to share his fear with others.C. D. p. Leave me alone. stress.” Rationale: Correct: This information must be shared as it influences his plan of care.

J. Fundamentals of nursing: Concepts. Encourage Michel’s mother to participate in his care. A. 2) TPR and BP. (2006). N. & Snyder. M. G.: Pearson Prentice Hall. Erb. Erb. Louis. St.). J.. Kozier.). (2004). Michel. M. Berman. (2007).Rationale: Incorrect: The nurse should maintain confidentiality.: Pearson Prentice Hall. S. References: Hockenberry. ON: Elsevier Mosby. refusing to speak. who is accompanied by his mother. (2006). and breath sounds Rationale: Incorrect: Anterior-posterior diameter does not provide data for emergency care and BP not critical at this point.). B.C. The nurse completes a focused history. Berman. Wong’s nursing care of infants and children (8th ed. 323-324. p. Canadian fundamentals of nursing (3rd ed. Toronto. M. p. & Wood. He has an audible wheeze and is diaphoretic. & Wilson. & Wood.C.). A. Upper Saddle River. and practice (7th ed. 92 Question 92 Joshua. 15 years old. B. process. is being admitted to the hospital with a new diagnosis of diabetes (Type 1). and practice (7th ed. Maternal and child nursing: Care of the childbearing and childrearing family (5th ed. says. Emphasize the possible complications if he fails to adhere to the prescribed treatment. (2004). SaO2. Pillitteri. 1279.). peak flow measurement. 329. He is accompanied by his grandmother who tells the nurse he was diagnosed with asthma 3 years ago. and use of accessory muscles Rationale: Incorrect: Not critical to assess BP initially because it does not provide data to address respiratory emergency. the nurse notes that Michel expresses some doubt about his ability to manage his diabetes. 235. Rationale: Incorrect: This promotes dependence on his mother rather than self care. What should the nurse do to promote self-care in Michel? *1) Ask Michel to tell her what he has learned. Leave me alone.J.).” He sits on the bed and looks at the wall. p. Missouri: Elsevier Mosby. Canadian fundamentals of nursing (3rd ed. Rationale: Incorrect: This will not promote self care and may foster dependency. 2) Request that Michel’s hospital stay be extended. Fundamentals of nursing: Concepts. “I don’t want any needles.. D.. He is to receive insulin. ON: Elsevier Mosby. the nurse identifies areas of weakness to guide further instruction and reinforces his confidence in his present knowledge. 4) Pulse and respiratory rate. A. Rationale: Incorrect: This increases anxiety and reinforces feelings of doubt. SaO2. and anterior-posterior diameter Rationale: Incorrect: Peak flow measurement and anterior-posterior diameter are not critical in planning acute care. S.J. p. *3) Pulse and respiratory rate. process. gasping for breath. and breath sounds Rationale: Correct: This data is critical in planning acute emergency care.). N.J. (ed. Rationale: Correct: By assessing his level of knowledge. anterior-posterior diameter. (2007). p. Kerr. (ed. 454. 1284-1286. 3) 4) References: Kozier. & Snyder. During the discharge interview. Toronto. Joshua is sitting upright on the stretcher. G. arrives by ambulance at the Emergency Department presenting with an acute asthmatic episode. Upper Saddle River. References: Kerr. J. 8 years old.). 91 Question 91 Michel.. Philadelphia: . Which of the following physical assessment information must be gathered immediately to assure safe care for Joshua? 1) TPR and BP.

Maternal and child nursing: Care of the childbearing and childrearing family (5th ed.). Joshua becomes cyanotic. Wong’s nursing care of infants and children (8th ed. 1260. (2007). gasping for breath. Kacmarek. Joshua is sitting upright on the stretcher. (2005). Rationale: Incorrect: Cyanosis and cessation of audible wheeze suggest impending respiratory failure. Williams & Wilkins. increase oxygen flow rate and prepare to transfer to the Intensive Care Unit. Pillitteri. St. 93 Question 93 Joshua. 94 Question 94 Joshua. sustained a head injury when she fell off a swing in a park playground. 534-535. He has an audible wheeze and is diaphoretic. Rationale: Correct: Joshua is exhibiting signs of respiratory failure and he will need critical care. S. He is accompanied by his grandmother who tells the nurse he was diagnosed with asthma 3 years ago. arrives by ambulance at the Emergency Department presenting with an acute asthmatic episode. arrives by ambulance at the Emergency Department presenting with an acute asthmatic episode. 2) Allow Joshua to rest. 1229-1230. & Wilson. Louis. Rationale: Incorrect: PaO2 does not increase with acute respiratory distress *2) Decreased PaO2 with increased PaCO2. p. St. A. *3) Check oxygen saturation. Rationale: Incorrect: PaCO2 does not decrease in acute respiratory distress 4) References: Hockenberry. 95 Question 95 Holly. M. p. Rationale: Incorrect: Cyanosis and cessation of audible wheeze suggest impending respiratory failure.). Rationale: Incorrect: Joshua is exhibiting signs of respiratory failure and needs immediate attention. Which would be the most appropriate action for the nurse to take? 1) Increase the oxygen rate and reassure Joshua’s grandmother that his wheeze is improving. document the change in his condition and reassess him in 15 min. MO: Elsevier Mosby. & Dimas. Rationale: Incorrect: PaO2 does not increase with acute respiratory distress Decreased PaCO2 with decreased pH. She has remained in hospital in an unconscious state for 5 days. & Wilson. 4) Raise the head of the bed. References: Hockenberry. p. 8 years old. Missouri: Elsevier Mosby. Wong’s nursing care of infants and children (8th ed. Which one of the following means of stimulation should the nurse use to communicate with Holly? . Missouri: Elsevier Mosby. R. (2007). 8 years old. Which of the following changes in arterial blood gases (ABGs) would reflect a significant deterioration in Joshua’s condition? 1) Increased PaO2 with decreased PaCO2. (2007). M. p. St. 1302. gasping for breath.) Philadelphia: Lippincott. Rationale: Correct: These findings reflect respiratory acidosis in keeping with acute respiratory distress. 1286. 8 years old. decrease oxygen flow rate and reassess in 15 min. D. Williams & Wilkins. Joshua is sitting upright on the stretcher. The essentials of respiratory care (4th ed. He is accompanied by his grandmother who tells the nurse he was diagnosed with asthma 3 years ago. He has an audible wheeze and is diaphoretic. 3) Increased PaO2 with decreased pH. Louis.Lippincott. his respiratory rate is 8 breathes per minute and he no longer has an audible wheeze. p.). Louis. D.

J. Rationale: Incorrect: Stimulation provided by a television program is not as direct and interactive as that provided by the nurse’s voice and touch. 8 years old. Rationale: Incorrect: For an unconscious client. Williams & Wilkins. (2007). 2) *3) Talk to Holly as care is being given. . Check for the integrity of the catheter balloon after insertion. In addition. visual stimulation is not appropriate as hearing is the last sense lost. Holly remains unresponsive.) Philadelphia: Lippincott.. 1365. Erb. 329.). B. M. Rationale: Incorrect: Lemon and glycerin freshen with no cleansing function. 96 Question 96 Holly. A. (2004). & Wilson. sustained a head injury when she fell off a swing in a park playground. Rationale: Incorrect: The integrity of the balloon is assessed prior to insertion. M. Canadian fundamentals of nursing (3rd ed. Wong’s nursing care of infants and children (8th ed.). S. Toronto. She has remained in hospital in an unconscious state for 5 days. References: Hockenberry. Rationale: Correct: The interactive stimulation provided by the nurse’s voice and touch as she provides care is the best means of communication. (2007). Kozier. sustained a head injury when she fell off a swing in a park playground. Which one of the following procedures should the nurse follow when inserting an indwelling catheter? 1) sterile water to lubricate the tip of the indwelling catheter. and practice (7th ed. An indwelling catheter is ordered for Holly. glycerin dries the mouth. She has remained in hospital in an unconscious state for 5 days.. References: Kerr.1) Put a picture of her mother by Holly’s bedside. Rationale: Incorrect: Stimulation provided by an audio tape is not as direct and interactive as the nurse’s voice and touch. p. J. How should the nurse perform mouth care? 1) Clean her tongue with lemon and glycerin. Pillitteri. (2006). 97 Question 97 Holly. G.J. 4) Turn on a children’s television program. St. ON: Elsevier Mosby.).C. Rationale: Correct: Inserting the catheter beyond the point where urine begins to flow ensures the balloon will be inflated in the bladder. 3) *4) Insert the catheter beyond the point at which the urine begins to flow.).: Pearson Prentice Hall. Missouri: Elsevier Mosby. 2) Drain no more than 100 mL from the bladder and then clamp the catheter. A. Rationale: Incorrect: The lubricant of choice when inserting an indwelling catheter is a water-soluble lubricant. Maternal and child nursing: Care of the childbearing and childrearing family (5th ed. p. & Wood. (ed. Rationale: Incorrect: A retention catheter remains in the bladder and is not removed after 100 mL of urine is drained. 1630. Rationale: Incorrect: A soft toothbrush should be used for cleaning teeth. 8 years old. 2) Brush her teeth with a firm toothbrush. Upper Saddle River. Louis. process. Fundamentals of nursing: Concepts.1046. N. D. Play a tape of Holly’s favourite songs. It is also unnecessary to clamp the catheter for this client. p. Berman. & Snyder. p.

3) 4) References: Arnold.J. N. 2) “Am I not involving them enough?” Rationale: Incorrect: A closed-ended question discourages elaboration. N.C. J. G. Upper Saddle River. Rationale: Incorrect: Hyperextension is not required for oral suctioning..) Philadelphia: Lippincott. Toronto.) St. & Snyder. 1055. Canadian fundamentals of nursing (3rd ed. & Wood. p. sustained a head injury when she fell off a swing in a park playground. (2006). S. Fundamentals of nursing: Concepts.. sustained a head injury when she fell off a swing in a park playground. B. 727.U. (2004). 8 years old. 1854. when secretions are audible). Erb. “You should be involving the family. Interpersonal relationships: Professional communication skills for nurses (5th ed. References: Kozier. M. *2) Place Holly in a lateral position facing the nurse. Rationale: Incorrect: Clients should be suctioned only as necessary (e. S.3) Rinse her mouth with 30 mL of warm saline solution. Rationale: Correct: A lateral position allows the tongue of the unconscious client to fall forward so that it will not obstruct the catheter on insertion. “I feel I have assessed this situation appropriately. p. and practice (7th ed. Berman. (2004). Williams & Wilkins.C. & Bare. 8 years old. & Snyder. and practice (7th ed.. (ed. process. & Boggs. 1319. Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed.” Rationale: Incorrect: This is a defensive response. p.).). It blocks communication.. G. S.J. Haven’t you thought about this?” Which of the following responses would best address the colleague’s concern? *1) “What suggestions do you have?” Rationale: Correct: The nurse asks for further elaboration. 99 Question 99 Holly. *4) Clean her mouth with a moistened sponge stick (toothette). process. B. Fundamentals of nursing: Concepts. Rationale: Incorrect: This action is incorrect because it could lead to laryngeal spasm. Rationale: Correct: Cleansing with moistened sponge stick will cleanse without excess water that could be aspirated. p. The nurse’s colleague states.g. Upper Saddle River.J.. Kerr. (2004).C. Louis. 98 Question 98 Holly. ON: Elsevier Mosby. A. p. Rationale: Incorrect: Rinsing fluids could be aspirated because the gag reflex may be absent in an unconscious client. K. She has remained in hospital in an unconscious state for 5 days. 3) Hyperextend Holly’s neck before inserting the catheter. Smeltzer. B.).: Pearson Prentice Hall. Insert the suction tip to the top of the larynx. 207. Berman.G.: Pearson Prentice Hall.” Rationale: Incorrect: This statement shuts down the communication process. 4) References: Kozier. She has remained in hospital in an unconscious state for 5 days. Erb. . This indicates an openness to further discussion. Which one of the following nursing measures should be implemented when performing oral suctioning on Holly? 1) Suction Holly routinely every hour. (2007). E. A. Missouri: Saunders Elsevier. “I have explained the care plan to them.).

Dress Holly in her own pajamas. Rationale: Incorrect: The type of clothing is not the issue. 2) Put Holly in a private room if one is available. ON: Elsevier Mosby.C.). J.). Rationale: Incorrect: Placing Holly in a private room does not guarantee privacy. How should the nurse best maintain Holly’s privacy? *1) Pull the curtains around the bed when bathing Holly. 274-276. (ed. (2006). 100 Question 100 Holly. Toronto.Kerr. Canadian fundamentals of nursing (3rd ed. provided that Holly is covered. p. sustained a head injury when she fell off a swing in a park playground. 8 years old. She has remained in hospital in an unconscious state for 5 days. Keep Holly’s door closed to prevent other children from visiting her. Rationale: Incorrect: Exposure to other children could benefit Holly and is not an invasion of her privacy. & Wood.J. 3) 4) . M. Rationale: Correct: Pulling the curtain around Holly’s bed while she is being bathed ensures that her privacy is maintained.