Question 1

A nurse is caring for a patient who has an amputation of a limb. The patient begins to experience extreme discomfort in the area where the limb once was. He is near crying and diaphoretic. The nurse wants to properly document the situation, but is not sure of what nursing diagnosis to use. She seeks help from her unit manager and was able to come up with the most appropriate nursing diagnosis, which is:

Accepted Answer

She seeks help from her unit manager and was able to come up with the most appropriate nursing diagnosis, which is chronic pain related to phantom limb phenomenon. Phantom limb sensation is a real experience with no known cause or cure, but over time, becomes less of an issue for the patient.

Question 2

A nurse is caring for a patient after a cervical neck injury and is placed in a halo brace with a body cast. The nurse determines that the appropriate nursing diagnosis is "body image disturbance." She executed several nursing actions to resolve the problem considering that the patient is hard to get along with at the beginning. What statement by the patient indicates that the problem has been resolved?

Accepted Answer

The statement by the patient that indicates that the problem has been resolved is "I've gotten used to the brace. I may never miss it when it's gone". This statement is a demonstration of acceptance and is even looking toward the future.

Question 3

A 60-year-old woman who has had a number of strokes refuses further life-sustaining intervention, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to proceed this way and her daughter agrees. An ethics consult has been placed. Who is the appropriate decision maker?

Accepted Answer

The appropriate decision maker is the patient. Because the patient is competent, she has the right to refuse therapy, even if this hastens her death.

Question 4

The new clinical nurse specialist is nervous and concerned about the work she is about to do at the clinical facility. To alleviate anxiety and be successful in her provision of care it is important for her to:

Accepted Answer

To alleviate anxiety and be successful in her provision of care, it is important for her to engage in self talk to plan her day and decrease her fear. Using intrapersonal communication, the new clinical nurse specialist can plan her day and enhance her clinical performance to decrease fear and anxiety.

Question 5

A nurse is caring for an adult patient who she thinks is at high risk for developing a pressure ulcer. As a clinical nurse specialist, one of her responsibilities is to implement clinical changes and research?based practices developed by others. Which of the following steps should the clinical nurse specialist avoid?

Accepted Answer

A step that a clinical nurse specialist should avoid is to look for a systematic research review about the issue. Limit the keywords to be able to come up with information about pressure ulcer prevention and management. Limiting the keywords will result in limited information; search words could include wound care, pressure ulcer, decubiti, and wound healing.

Question 6

During a nursing staff meeting, the nurses determine that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of:

Accepted Answer

- Ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity.

Question 7

A 55-year-old patient states "I have been experiencing complications of diabetes." The nurse directs the patient to provide more information. What is the most appropriate comment or question at this time?

Accepted Answer

The most appropriate comment or question at this time is "What specific complications have you experienced?" Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

Question 8

A nurse learns that using silence as a communication technique is effective for a family of a patient who is critically ill. She used it during morning nursing rounds because this technique assists the family to:

Accepted Answer

This technique assists the family to gather their thoughts. Silence allows the family to organize their thoughts and develop any questions specific to understanding the patient's care.

Question 9

A nurse learns from research and case studies that pain in orthopaedic cases may not be mainly due to the surgery. There might be other factors, such as cultural or psychological, that influence pain. A nurse can alter these factors by:

Accepted Answer

A nurse can alter these factors by promoting a sense of control and participation in control through listening to concerns. Promoting a patient's sense of control and a nurse's participation in control by listening to patient's concerns results in faster establishment of trust, thus aiding in easier nursing interventions to alleviate pain.

Question 10

A nurse is discussing the ordered dietary restrictions with a Chinese patient. During the teaching session, the patient continuously turns away from the nurse. Which would be the most appropriate nursing action?

Accepted Answer

The most appropriate nursing action is to tell the patient about the importance of the teaching to maintain health care. Many people of Chinese descent maintain a formal distance with others, which is a form of respect. They are uncomfortable with face-to-face communication, especially if there is direct eye contact.

Question 11

A nurse assisted a patient in getting back to his bed after a fall. The nurse and the attending physician have assessed the patient and determined that the patient is not injured. After completion of the incident report, the nurse should:

Accepted Answer

After completion of the incident report, the nurse should reassess the patient. The patient's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only those participating in the patient's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if a status update is desired. After a patient's fall, the nurse must frequently reassess the patient because potential complications do not always appear immediately after the fall.

Question 12

A nurse calls the physician about an order of a medication that has a high recommended dosage. The nurse wasn't able to locate the physician and the medication is already due to be administered. The nurse should:

Accepted Answer

The nurse should contact the nursing supervisor. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification.

Question 13

A nurse attends a 4 hour seminar as part of her continuing professional education. One of the topics includes low-risk therapies that can be useful to selected patients during confinement or discharge. She notes that low risk therapies include:

Accepted Answer

She notes that low risk therapies include massage, touch, and prayer. Other low-risk therapies are meditation, relaxation techniques, imagery, music therapy, laughter and humor, and spiritual measures.

Question 14

A clinical nurse specialist is caring for a terminally ill patient whose death is imminent. The nurse has established a close relationship with the immediate relative of the patient. What nursing intervention should a nurse avoid in dealing with the family during a difficult time?

Accepted Answer

A nursing intervention that a nurse should avoid in dealing with the family during a difficult time is making decisions for the family. Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication, as well as preserve the family's sense of self-direction and control.

Question 15

A nurse is caring for patient who is scheduled for nephrectomy due to a renal cell carcinoma of the right kidney. It appears that the left kidney is normal. The nurse observes that the patient is anxious and in doubt whether dialysis will ultimately be a necessity. The nurse should plan to use which information in discussing this with the patient?

Accepted Answer

When discussing this with the patient, the nurse should explain that one kidney is adequate to meet the needs of the body, so long as it has a normal function. This patient needs emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs.

Question 16

Which purpose best describes managed care as a framework for healthcare?

Accepted Answer

A purpose that best describes managed care as a framework for healthcare is that it is designed to control the cost of care while maintaining the quality of care.

Question 17

A clinical nurse specialist is reviewing a well-known journal of nursing as part of her duty to be informed on trends. She came across a topic related to respite care. At the end of the article, she was able to define respite care as:

Accepted Answer

At the end of the article, she was able to define respite care as a service that allows time away for caregivers. Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

Question 18

A 50-year-old male patient was admitted at the intensive care unit after a traumatic compressed spinal cord injury at the level of T6 and T7 and had above-the-knee amputation. A clinical nurse specialist is to perform an assessment to validate what she has learned from her senior nurse during the endorsement and would expect to observe that the patient is experiencing:

Accepted Answer

A clinical nurse specialist is to perform an assessment to validate what she has learned from her senior nurse during the endorsement and would expect to observe that the patient is experiencing pain at the level of compression. Pain is brought by the injury and pressure at the nerve roots. Paralysis could be true, but it is initially a flaccid type of paralysis.

Question 19

A 50-year-old deteriorating patient who suffered from third degree burns has a laboratory values of BUN 37 mg/dL; serum potassium of 6.3 mEq/L; pH of 7.1; PO2 of 90 mmHg; and hemoglobin of 7.4g/dL. This finding is indicative of:

Accepted Answer

The finding is indicative of azotemia. The BUN level is way above the normal or expected level. Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds in the blood.

Question 20

A male patient tells the nurse that his doctor just told him that his triglycerides and cholesterol are excessively beyond the normal ranges. The patient appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." The nurse's most appropriate response is:

Accepted Answer

The most appropriate advice would be to cut down the amount of fats in his diet since essential fatty acids (linoleic and linolenic acids) are necessary for muscle tissue integrity, especially of the myocardium. All fats should not be eliminated in the diet. Carbohydrates do not contain the essential fatty acids and the body does manufacture cholesterol.

Quiz 1: Adult