Which of the following principles or guidelines accurately informs the nurse regarding placebos? a) Placebos should never be used to test the person’s truthfulness about pain. Perception of pain is highly individualized. b) A placebo effect is an indication that the person does not have pain. A placebo effect is a true physiologic response. c) A placebo should be used as the first line of treatment for the patient. A placebo should never be used as a first line of treatment. d) A positive response to a placebo indicates that the person’s pain is not real. Reduction in pain as a response to placebo should never be interpreted as an indication that the person’s pain is not real.

Which of the following principles or guidelines accurately
informs the nurse regarding placebos?
a) Placebos should never be used to test the person’s truthfulness
about pain.
Perception of pain is highly individualized.
b) A placebo effect is an indication that the person does not have
pain.
A placebo effect is a true physiologic response.
c) A placebo should be used as the first line of treatment for the
patient.
A placebo should never be used as a first line of treatment.
d) A positive response to a placebo indicates that the person’s pain is
not real.
Reduction in pain as a response to placebo should never be interpreted
as an indication that the person’s pain is not real.
by

1 Answer

Answer :

a) Placebos should never be used to test the person’s truthfulness
about pain.
Perception of pain is highly individualized.
by

Related questions

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Description : Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, ... of burn pain. Pet therapy has not proven effective in the management of burn pain.

Last Answer : a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience ... orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma. b) normal. A class 1 Pap smear is interpreted as normal. c) probably normal. A class 2 Pap smear is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Description : When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, ... is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Last Answer : a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Which of the following is true of ‘placebos’: A. Placebo is a dummy medication B. Placebo is the inert material added to the drug for making tablets C. Placebos do not produce any effect D. All patients respond to placebos

Description : Which of the following is true of ‘placebos’: A. Placebo is a dummy medication B. Placebo is the inert material added to the drug for making tablets C. Placebos do not produce any effect D. All patients respond to placebos

Last Answer : A. Placebo is a dummy medication

Which of the following is true of ‘placebos’: A. Placebo is a dummy medication B. Placebo is the inert material added to the drug for making tablets C. Placebos do not produce any effect D. All patients respond to placebos

Description : Which of the following is true of ‘placebos’: A. Placebo is a dummy medication B. Placebo is the inert material added to the drug for making tablets C. Placebos do not produce any effect D. All patients respond to placebos

Last Answer : A. Placebo is a dummy medication

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

A steady state within the body is termed a) Homeostasis. When a change occurs that causes a body function to deviate from its stable range, processes are initiated to restore and maintain the steady state or homeostasis. b) Constancy. Constancy refers to the balanced internal state of the human body maintained by physiologic and biochemical processes. c) Adaptation. Adaptation refers to a constant, ongoing process that requires change in structure, function, or behavior so that the person is better suited to the environment. d) Stress. Stress refers to a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to the person’s dynamic balance or equilibrium.

Description : A steady state within the body is termed a) Homeostasis. When a change occurs that causes a body function to deviate from its stable range, processes are initiated to restore and maintain ... that is perceived as challenging, threatening, or damaging to the person's dynamic balance or equilibrium.

Last Answer : a) Homeostasis. When a change occurs that causes a body function to deviate from its stable range, processes are initiated to restore and maintain the steady state or homeostasis.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has a) injuries that are minor and treatment can be delayed hours to days. A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days.

Description : During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has a) injuries that are minor and treatment can be delayed hours to days. A ... or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

Last Answer : a) injuries that are minor and treatment can be delayed hours to days. A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

Description : The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly ... following a basal skull fracture. The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

Last Answer : a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a vial that is almost empty. She was able to aspirate 60 mg only. Nurse Kristine decided to inject it instead of making the client wait until the next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Description : The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding ... encouraged to void every 2-3 hours during the day and completely empty the bladder.

Last Answer : a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

Description : A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient's response to stimuli. A score of 7 or ... 3 is interpreted as least responsive. d) most responsive. A GCS score of 15 is interpreted as most responsive.

Last Answer : a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Description : After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Last Answer : A. Assess patency of the airway

43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Description : 43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Last Answer : A. “It seems that you are worried. Which matter to you more? What people will say or getting relief from your pain?”

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Description : When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a ... saline q8h as ordered The nurse may irrigate a nephrostomy tube with specific orders to do so.

Last Answer : a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Prostaglandins are chemical substances thought to a) increase sensitivity of pain receptors. Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. b) reduce the perception of pain. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. c) inhibit the transmission of pain. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. d) inhibit the transmission of noxious stimuli. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Description : Prostaglandins are chemical substances thought to a) increase sensitivity of pain receptors. Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking ... opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Last Answer : a) increase sensitivity of pain receptors. Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin.

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

Description : Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse ... avoid volunteering unnecessary information (e.g., patient was drinking at the time of the accident).

Last Answer : a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

Description : The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases ... in women who consume even one drink daily and doubles among women drinking three drinks daily.

Last Answer : a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds is the description given to auscultation of one to two bowel sounds in 2 minutes. c) sluggish. Sluggish is not a term a nurse would use to accurately describe bowel sounds. d) absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Description : When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds ... absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Last Answer : a) normal. Normal bowel sounds are heard every 5-20 seconds.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

The relaxation techniques of progressive muscle relaxation, relaxation with guided imagery, and the Benson Relaxation Response share which of the following elements? a) A mental device (something on which to focus the attention) Similar elements also include a quiet environment, a comfortable position, and a passive attitude. b) Nutritional foundation Relaxation techniques do not encompass specific nutritional guidelines. c) Analgesic preparation Relaxation techniques are used to reduce one’s response to stress and do not require analgesia prior to practicing the techniques. d) Physician’s order A physician’s order is not required to assist an individual to learn techniques to reduce one’s response to stress.

Description : The relaxation techniques of progressive muscle relaxation, relaxation with guided imagery, and the Benson Relaxation Response share which of the following elements? a) A mental device (something on which ... required to assist an individual to learn techniques to reduce one's response to stress.

Last Answer : a) A mental device (something on which to focus the attention) Similar elements also include a quiet environment, a comfortable position, and a passive attitude.

For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. b) Increased wakefulness As the body weakens, the patient will sleep more and begin to detach from the environment. c) Increased eating For many patients, refusal of food is an indication that they are ready to die. d) Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Description : 54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Last Answer : C. Round the clock on a consistent basis

Which of the following types of cells have a latent ability to regenerate? a) Stable Stable cells have a latent ability to regenerate if they are damaged or destroyed and are found in the kidney, liver, and pancreas, among other body organs. b) Labile Labile cells multiply constantly to replace cells worn out by normal physiologic processes. c) Permanent Permanent cells include neurons — the nerve cell bodies, not their axons. Destruction of a neuron causes permanent loss, but axons may regenerate. d) Epithelial Epithelial cells are a type of labile cell that multiply constantly to replace cells worn out by normal physiologic processes.

Description : Which of the following types of cells have a latent ability to regenerate? a) Stable Stable cells have a latent ability to regenerate if they are damaged or destroyed and are found in the ... a type of labile cell that multiply constantly to replace cells worn out by normal physiologic processes.

Last Answer : a) Stable Stable cells have a latent ability to regenerate if they are damaged or destroyed and are found in the kidney, liver, and pancreas, among other body organs.

The basic difference between nursing diagnoses and collaborative problems is that a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic complications that nurses monitor to detect onset or changes and manage through the use of physician-prescribed and nursing-prescribed interventions to minimize the complications of events.

Description : The basic difference between nursing diagnoses and collaborative problems is that a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic ... or potential health problems that can be managed by independent nursing interventions.

Last Answer : a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic complications that nurses monitor to detect onset or changes and manage ... physician-prescribed and nursing-prescribed interventions to minimize the complications of events.

According to Maslow, which of the following categories of needs represents the most basic? a) Physiologic needs Physiologic needs must be met before an individual is able to move toward psychological health and well-being. b) Self-actualization Self-actualization is the highest level of need c) Safety and security needs Safety and security needs, while lower level, are not essential to physiologic survival. d) Belongingness Belongingness and affection needs are not essential to physiologic survival.

Description : According to Maslow, which of the following categories of needs represents the most basic? a) Physiologic needs Physiologic needs must be met before an individual is able to move ... physiologic survival. d) Belongingness Belongingness and affection needs are not essential to physiologic survival.

Last Answer : a) Physiologic needs Physiologic needs must be met before an individual is able to move toward psychological health and well-being.

Asking the patient questions to determine if the person understands the health teaching provided would be included during which step of the nursing process? a) Evaluation Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes. b) Assessment Assessment includes determining the patient’s readiness regarding learning. c) Planning and goals Planning includes identification of teaching strategies and writing the teaching plan. d) Implementation Implementation is the step during which the teaching plan is put into action.

Description : Asking the patient questions to determine if the person understands the health teaching provided would be included during which step of the nursing process? a) Evaluation Evaluation includes observing ... ) Implementation Implementation is the step during which the teaching plan is put into action.

Last Answer : a) Evaluation Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding