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.

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.
by

1 Answer

Answer :

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

Related questions

A classic sign of cardiogenic shock is a) Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). b) High blood pressure Low blood pressure is a classic sign of cardiogenic shock. c) Hyperactive bowel sounds Hypoactive bowel sounds are classic signs of cardiogenic shock. d) Increased urinary output Decreased urinary output is a classic sign of cardiogenic shock.

Description : A classic sign of cardiogenic shock is a) Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). b) High blood pressure Low blood pressure is ... . d) Increased urinary output Decreased urinary output is a classic sign of cardiogenic shock.

Last Answer : a) Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

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.

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.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

Which of the following is a reversible cause of urinary incontinence in the older adult? a) Constipation. Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased fluid intake, a change in a chronic disease pattern, and decreased estrogen levels in the menopausal women.

Description : Which of the following is a reversible cause of urinary incontinence in the older adult? a) Constipation. Constipation is a reversible cause of urinary incontinence in the older adult. Other ... level in the menopausal woman is a reversible cause of urinary incontinence in the older woman.

Last Answer : a) Constipation. Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased ... a change in a chronic disease pattern, and decreased estrogen levels in the menopausal women.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of left-heart failure. b) Increased appetite Loss of appetite should be reported immediately. c) Weight loss Weight gain should be reported immediately. d) Ability to sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

Description : When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess ... anemia Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.

Last Answer : a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

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.

Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints. b) achalasia. Achalasia presents as difficulty in swallowing both liquids and solids. c) gastroesophageal reflux. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in or pain upon swallowing. d) hiatal hernia. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Description : Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour ... as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Last Answer : a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints.

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Ageism refers to a) Bias against older people based solely on chronological age Individuals demonstrating ageism base their beliefs and attitudes about older people based upon chronological age without consideration of functional capacity. b) fear of old age. Fear of aging and the inability of many to confront their own aging process may trigger ageist beliefs. c) loss of memory. Age-related loss of memory occurs more with short-term and recent memory. d) benign senescent forgetfulness. Benign senescent forgetfulness refers to the age-related loss of memory in the absence of a pathologic process.

Description : Ageism refers to a) Bias against older people based solely on chronological age Individuals demonstrating ageism base their beliefs and attitudes about older people based upon chronological age without consideration ... refers to the age-related loss of memory in the absence of a pathologic process.

Last Answer : a) Bias against older people based solely on chronological age Individuals demonstrating ageism base their beliefs and attitudes about older people based upon chronological age without consideration of functional capacity.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Which of the following medications used for the treatment of obesity prevents the absorption of triglycerides? a) Orlistat (Xenical) Orlistat (Xenical) prevents the absorption of triglycerides. Side effects of Xenical may include increased bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. b) bupropion hydrochloride (Wellbutrin) buproprion hydrochloride (Wellbutrin) is an antidepressant medication. c) Sibutramine hydrochoride (Meridia) Sibutramine hydrochloride (Meridia) inhibits the reuptake of serotonin and norepinephine. Meridia decreases appetite. d) Fluoxetine hydrochloride (Prozac) Fluoxetine hydrochloride (Prozac) has not been approved by the FDA for use in the treatment of obesity.

Description : Which of the following medications used for the treatment of obesity prevents the absorption of triglycerides? a) Orlistat (Xenical) Orlistat (Xenical) prevents the absorption of triglycerides. Side effects of ... (Prozac) has not been approved by the FDA for use in the treatment of obesity.

Last Answer : a) Orlistat (Xenical) Orlistat (Xenical) prevents the absorption of triglycerides. Side effects of Xenical may include increased bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins.

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

Description : Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP ... regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

Last Answer : a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ failure. Which of the following statement(s) is/are true concerning necessary changes to be made in his nutritional management? a. Carbohydrate load should be reduced in the face of respiratory failure b. In patients with renal failure, protein intake should be diminished c. During hemodialysis protein intake should be limited to the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Description : A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ ... the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Last Answer : Answer: a, b The most severe complication of sepsis is multiple system organ dysfunction syndrome, which may result in death. The development of organ failure requires changes in the ... should be provided as fat emulsion. If encephalopathy develops, protein load should also be reduced0

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

In which range of body mass index (BMI) are patients considered to have increased risk for problems associated with poor nutritional status? a) Below 24 Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are associated with individuals who have low BMI. b) 25-29 Those who have a BMI of 25 to 29 are considered overweight. c) 30 to 39 Those who have BMI of 30-39 are considered obese. d) Over 40 Those who have BMI over 40 are considered extremely obese.

Description : In which range of body mass index (BMI) are patients considered to have increased risk for problems associated with poor nutritional status? a) Below 24 Additionally, higher mortality rates in hospitalized ... considered obese. d) Over 40 Those who have BMI over 40 are considered extremely obese.

Last Answer : a) Below 24 Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are associated with individuals who have low BMI.

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.

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.

Which of the following diseases is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain? a) Parkinson’s disease In some patients, Parkinson’s disease can be controlled; however, it cannot be cured.

Description : Which of the following diseases is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain? a) ... of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

Last Answer : a) Parkinson’s disease In some patients, Parkinson’s disease can be controlled; however, it cannot be cured.

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.

Nondisjunction of a chromosome results in which of the following diagnoses? a) Down Syndrome When a pair of chromosomes fails to separate completely and creates a sperm or oocyte that contains two copies of a particular chromosome (nondisjunction) Down syndrome results from three number 21 chromosomes. b) Huntingon Disease Huntington disease is one example of a germ-line mutation. c) Duchenne Muscular Dystrophy Duchenne muscular dystrophy, an inherited form of muscular dystrophy, is an example of a genetic caused by structural gene mutations. d) Marphan Syndrome Marphan Syndrome is a genetic condition that may occur in a single family member as a result of spontaneous mutation.

Description : Nondisjunction of a chromosome results in which of the following diagnoses? a) Down Syndrome When a pair of chromosomes fails to separate completely and creates a sperm or oocyte that contains two ... genetic condition that may occur in a single family member as a result of spontaneous mutation.

Last Answer : a) Down Syndrome When a pair of chromosomes fails to separate completely and creates a sperm or oocyte that contains two copies of a particular chromosome (nondisjunction) Down syndrome results from three number 21 chromosomes.

Which of the following statements regarding hypercalcemia are true? A. The symptoms of hypercalcemia may mimic some symptoms of hyperglycemia. B. Metastatic breast cancer is an unusual cause of hypercalcemia. C. Calcitonin is a satisfactory long-term therapy for hypercalcemia. D. Severely hypercalcemic patients exhibit the signs of extracellular fluid volume deficit. E. Urinary calcium excretion may be increased by vigorous volume repletion.

Description : Which of the following statements regarding hypercalcemia are true? A. The symptoms of hypercalcemia may mimic some symptoms of hyperglycemia. B. Metastatic breast cancer is an unusual cause of ... fluid volume deficit. E. Urinary calcium excretion may be increased by vigorous volume repletion.

Last Answer : Answer: ADE DISCUSSION: Markedly elevated serum calcium levels produce polydipsia, polyuria, and thirst. Vigorous volume repletion and saline diuresis correct the extracellular fluid volume ... , from bony metastasis. The calcitonin effect on calcium is diminished with repeat administrations

Answer: b Metabolic response to injury results in increased energy expenditure. If energy intake is less than expenditure, oxidation of body fat stores and erosion of lean body mass will occur with resultant loss of weight. When weight loss exceeds 10–15% of body weight, the complications of malnutrition interact with disease processes, with increased morbidity and mortality rates. The goal of nutritional support is maintenance of body cell mass and limitation of weight loss to less than 10% preinjury. The major impact of nutritional support in the trauma patient is to aid host defense. Under-nutrition may compromise the available host defense mechanism and may thus increase the likelihood of invasive sepsis, multiple organ system failure, and death. Resuscitation, oxygenation and arrest

Description : Answer: b Metabolic response to injury results in increased energy expenditure. If energy intake is less than expenditure, oxidation of body fat stores and erosion of lean body mass will occur ... requirements, caloric requirements should be distributed at a ratio of 70% as glucose and 30% as fat

Last Answer : Which of the following statement(s) is/are true concerning body fuel reserves? a. The largest fuel reserve in the body is skeletal muscle b. Fat provides about 9 calories/gram c. Free glucose and glycogen stores are a trivial fuel reserve d. Body protein is a valuable storage form of energy

Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

Description : Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor ... for immediate hospitalization. The patient with severe OHSS is hospitalized for monitoring and treatment.

Last Answer : a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be masked by the hyponatremia. C. Oliguric renal failure is an unlikely complication. D. Rapid correction of the hyponatremia may prevent central pontine injury. E. This patient is best treated by restriction of water intake.

Description : Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be ... central pontine injury. E. This patient is best treated by restriction of water intake.

Last Answer : Answer: A DISCUSSION: Acute symptomatic hyponatremia is characterized by central nervous system signs of increased intracranial pressure. Changes in blood pressure and pulse are secondary to ... lead to central pontine myelinolysis. Oliguric renal failure may rapidly develop in severe hyponatremia

Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Decreased or absent deep tendon reflexes Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes.

Description : Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Decreased or absent deep ... and movement times Strength and agility are diminished and reaction and movement times are decreased.

Last Answer : a) Decreased or absent deep tendon reflexes Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes.

Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more than 90 per cent of HIV infected patients as the immune function deteriorates. Common complaints include pruritis, folliculitis, and chronic actinic dermatitis.

Description : Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more ... Decrease in normal skin flora Cutaneous signs of HIV disease appear as immune function deteriorates.

Last Answer : a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more than 90 per cent of HIV infected patients as the immune function deteriorates. Common complaints include pruritis, folliculitis, and chronic actinic dermatitis.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

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 nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

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.

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.

An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Description : An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics ... Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Last Answer : a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

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.

Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

Description : Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. ... -Hallpike procedure. The Dix-Hallpike test is an assessment test used to evaluate for BPPV.

Last Answer : a) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

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.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues? a) Biofeedback Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback. b) Kegel exercises Kegel exercises are pelvic floor exercises that strengthen the pubococcygeus muscle. c) Habit training Habit training is used to try to keep the patient dry by strictly adhering to a toileting schedule and may be successful with stress, urge, or functional incontinence. d) Bladder training Habit training is a type of bladder training.

Description : Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues? a) Biofeedback Cognitively intact patients who have stress or urge ... functional incontinence. d) Bladder training Habit training is a type of bladder training.

Last Answer : a) Biofeedback Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback.

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.