Go! 23.

In acute glaucoma, the obstruction of the

flow of aqueous humor is caused by
1. Bone scan is done by injecting radioisotope displacement of the iris.
per IV & X-rays are taken. 24. Glaucoma is characterized by irreversible
2. To prevent edema edema on the site of blindness.
sprain, apply cold compress on the area for the 25. Hyperopia is corrected by convex lens.
1st 24 hrs 26. Pterygium is caused primarily by exposure to
3. To turn the client after lumbar Laminectomy, dust.
use logrolling technique 27. A sterile chronic granulomatous inflammation
4. Carpal tunnel syndrome occurs due to the of the meibomian gland is chalazion.
injury of median nerve. 28. The surgical procedure w/c involves removal
5. Massaging the back of the head is of the eyeball is enucleation.
specifically important for the client w/ 29. Snellen’s Test assesses visual acuity.
Crutchfield tong. 30. Presbyopia is an eye disorder characterized
6. A 1 yr old child has a fracture of the L femur. by lessening of the effective powers
He is placed in Bryant’s traction. The reason for of accommodation.
elevation of his both legs at 90 deg. angle is his 31. The primary problem in cataract is blurring
weight isn’t adequate to provide sufficient of vision.
countertraction, so his entire body must be 32. The primary reason for performing
used. iridectomy after cataract extraction is to prevent
7. Swing-through crutch gait is done by secondary glaucoma.
advancing both crutches together & the client 33. In acute glaucoma, the obstruction of the
moves both legs past the level of the crutches. flow of aqueous humor is caused by
8. The appropriate nursing measure to prevent displacement of the iris.
displacement of the prosthesis after a right total 34. Glaucoma is characterized by irreversible
hip replacement for arthritis is to place the blindness.
patient in the position of right leg abducted. 35. Hyperopia is corrected by convex lens.
9. Pain on non-use of joints, subcutaneous 36. Pterygium is caused primarily by exposure to
nodules & elevated ESR are characteristic dust.
manifestations of rheumatoid arthritis. 37. A sterile chronic granulomatous inflammation
10. Teaching program of a patient w/ SLE should of the meibomian gland is chalazion.
include emphasis on walking in shaded area. 38. The surgical procedure w/c involves removal
11. Otosclerosis is characterized by replacement of the eyeball is enucleation.
of normal bones by spongy & highly 39. The client is for EEG this morning. Prepare
vascularized bones. him for the procedure by rendering hair
12. Use of high pitched voice is inappropriate for shampoo, excluding caffeine from his meal &
the client w/ hearing impairment. instructing the client to remain still during the
13. Rinne’s test compares air conduction w/ procedure.
bone conduction. 40. If the client w/ increased ICP demonstrates
14. Vertigo is the most characteristic decorticate posturing, observe for flexion of
manifestation of Meniere’s disease. elbows, extension of the knees, plantar flexion
15. Low sodium is the diet for a client w/ of the feet,
Meniere’s disease. 41. The nursing diagnosis that would have the
16. A client who had cataract surgery should be highest priority in the care of the client who has
told to call his MD if he has eye pain. become comatose following cerebral
17. Risk for Injury takes priority for a client w/ hemorrhage is Ineffective Airway Clearance.
Meniere’s disease. 42. The initial nursing action—for a client who is
18. Irrigate the eye w/ sterile saline is the in the clonic phase of a tonic-clonic seizure—is
priority nursing intervention when the client has to obtain equipment for orotracheal suctioning.
a foreign body protruding from the eye. 43. The first nursing intervention in a
19. Snellen’s Test assesses visual acuity. quadriplegic client who is experiencing
20. Presbyopia is an eye disorder characterized autonomic dysreflexia is to elevate his head as
by lessening of the effective powers high as possible.
of accommodation. 44. Following surgery for a brain tumor near the
21. The primary problem in cataract is blurring hypothalamus, the nursing assessment should
of vision. include observing for inability to regulate body
22. The primary reason for performing temp.
iridectomy after cataract extraction is to prevent 45. Post-myelogram (using metrizamide
secondary glaucoma. (Amipaque) care includes keeping head elevated
for at least 8 hrs.
46. Homonymous hemianopsia is described by a 68. First-morning urine provides the best sample
client had CVA & can only see the nasal visual to measure glucose, ketone, pH, and specific
field on one side & the temporal portion on the gravity values.
opposite side. 69. To induce sleep, the first step is to minimize
47. Ticlopidine may be prescribed to prevent environmental stimuli.
thromboembolic CVA. 70. Before moving a patient, the nurse should
48. To maintain airway patency during a stroke assess the patient’sv physical abilities and ability
in evolution, have orotracheal suction available to understand instructions as well as the
at all times. amount of strength required to move the
49. For a client w/ CVA, the gag reflux must patient.
return before the client is fed. 71. To lose 1 lb (0.5 kg) in 1 week, the patient
50. Clear fluids draining from the nose of a client must decrease his weeklyv intake by 3,500
who had a head trauma 3 hrs ago may calories (approximately 500 calories daily). To
indicate basilar skull fracture. lose 2 lb (1 kg) in 1 week, the patient must
51. An adverse effect of gingival hyperplasia decrease his weekly caloric intake by 7,000
may occur during Phenytoin (DIlantin) therapy. calories (approximately 1,000 calories daily).
52. Urine output increased: best shows that the 72. To avoid shearing force injury, a patient who
mannitol is effective in a client w/ increased is completely immobile is lifted on a sheet.
ICP. 73. To insert a catheter from the nose through
53. A client w/ C6 spinal injury would most likely the trachea for suction, the nurse should ask the
have the symptom of quadriplegia. patient to swallow.
54. Falls are the leading cause of injury in 74. Vitamin C is needed for collagen production.
elderly people. 75. Only the patient can describe his pain
55. Primary prevention is true prevention. accurately.
Examples are immunizations, weight control, 76. Cutaneous stimulation creates the release of
and smoking cessation. endorphins that block the transmission of pain
56. Secondary prevention is early detection. stimuli.
Examples include purifiedv 77. Patient-controlled analgesia is a safe method
protein derivative (PPD), breast self- to relieve acute painv caused by surgical
examination, testicular self-examination, and incision, traumatic injury, labor and delivery, or
chest X-ray. cancer.
57. Tertiary prevention is treatment to prevent 78. An Asian American or European American
long-term complications. typically places distance between himself and
58. A patient indicates that he’s coming to terms others when communicating.
with having a chronic disease when he says, 79. Active euthanasia is actively helping a person
“I’m never going to get any better.” to die.
59. On noticing religious artifacts and literature 80. Brain death is irreversible cessation of all
on a patient’s nightv stand, a culturally aware brain function.
nurse would ask the patient the meaning of the 81. Passive euthanasia is stopping the therapy
items. that’s sustaining life.
60. A Mexican patient may request the 82. A third-party payer is an insurance company.
intervention of a curandero, orv faith healer, 83. Utilization review is performed to determine
who involves the family in healing the patient. whether the care provided to a patient was
61. In an infant, the normal hemoglobin value is appropriate and cost-effective.
12 g/dl. 84. A value cohort is a group of people who
62. The nitrogen balance estimates the experienced an out-of-the-ordinary event that
difference between the intake and use of shaped their values.
protein. 85. Voluntary euthanasia is actively helping a
63. Most of the absorption of water occurs in the patient to die at the patient’s request.
large intestine. 86. Bananas, citrus fruits, and potatoes are good
64. Most nutrients are absorbed in the small sources of potassium.
intestine. 87. Good sources of magnesium include fish,
65. When assessing a patient’s eating habits, the nuts, and grains.
nurse should ask, “What have you eaten in the 88. Beef, oysters, shrimp, scallops, spinach,
last 24 hours?” beets, and greens are good sources of iron.
66. A vegan diet should include an abundant 89. Intrathecal injection is administering a drug
supply of fiber. through the spine.
67. A hypotonic enema softens the feces, 90. When a patient asks a question or makes a
distends the colon, and stimulates peristalsis. statement that’sv emotionally charged, the
nurse should respond to the emotion behind the
 statement or question rather than to what’s 117. Discrimination is preferential treatment of
being said or asked. individuals of a particular group. It’s usually
91. The steps of the trajectory-nursing model discussed in a negative sense.
are as follows: 118. Increased gastric motility interferes with the
92. – Step 1: Identifying the trajectory phase absorption of oral drugs.
93. – Step 2: Identifying the problems and 119. The three phases of the therapeutic
establishing goals relationship are orientation, working, and
94. – Step 3: Establishing a plan to meet the termination.
goals 120. Patients often exhibit resistive and
95. – Step 4: Identifying factors that facilitate or challenging behaviors in the orientation phase of
hinder attainment of the goals the therapeutic relationship.
96. – Step 5: Implementing interventions 121. Abdominal assessment is performed in the
97. – Step 6: Evaluating the effectiveness of the following order: inspection, auscultation,
interventions palpation, and percussion.
98. A Hindu patient is likely to request a 122. When measuring blood pressure in a
vegetarian diet. neonate, the nurse should select a cuff that’s no
99. Pain threshold, or pain sensation, is the less than one-half and no more than two-thirds
initial point at which a patient feels pain. the length of the extremity that’s used.
100. The difference between acute pain and 123. When administering a drug by Z-track, the
chronic pain is its duration. nurse shouldn’t use thev same needle that was
101. Referred pain is pain that’s felt at a site used to draw the drug into the syringe because
other than its origin. doing so could stain the skin.
102. Alleviating pain by performing a back 124. Sites for intradermal injection include the
massage is consistent with the gate control inner arm, the upper chest, and on the back,
theory. under the scapula.
103. Romberg’s test is a test for balance or gait. 125. When evaluating whether an answer on an
104. Pain seems more intense at night because examination is correct, thev nurse should
the patient isn’t distracted by daily activities. consider whether the action that’s described
105. Older patients commonly don’t report pain promotes autonomy (independence), safety,
because of fear of treatment, lifestyle changes, self-esteem, and a sense of belonging.
or dependency. 126. Veracity is truth and is an essential
106. No pork or pork products are allowed in a component of a therapeutic relationship
Muslim diet. between a health care provider and his patient.
107. Two goals of Healthy People 2010 are: 127. Beneficence is the duty to do no harm and
108. – Help individuals of all ages to increase the the duty to do good.v There’s an obligation in
quality of life and the number of years of patient care to do no harm and an equal
optimal health obligation to assist the patient.
109. – Eliminate health disparities among 128. Nonmaleficence is the duty to do no harm.
different segments of the population. 129. Frye’s ABCDE cascade provides a framework
110. A community nurse is serving as a patient’s for prioritizing care by identifying the most
advocate if she tells av malnourished patient to important treatment concerns.
go to a meal program at a local park. 130. A = Airway. This category includes
111. If a patient isn’t following his treatment plan, everything that affects a patentv airway,
the nurse should first ask why. including a foreign object, fluid from an upper
112. When a patient is ill, it’s essential for the respiratory infection, and edema from trauma or
members of his family to maintain an allergic reaction.
communication about his health needs. 131. B = Breathing. This category includes
113. Ethnocentrism is the universal belief that everything that affects thev breathing pattern,
one’s way of life is superior to others’. including hyperventilation or hypoventilation and
114. When a nurse is communicating with a abnormal breathing patterns, such as
patient through an interpreter,v the nurse Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
should speak to the patient and the interpreter. 132. C = Circulation. This category includes
115. In accordance with the “hot-cold” system everything that affects thev circulation,
used by some Mexicans,v Puerto Ricans, and including fluid and electrolyte disturbances and
other Hispanic and Latino groups, most foods, disease processes that affect cardiac output.
beverages, herbs, and drugs are described as 133. D = Disease processes. If the patient has no
“cold.” problem with the airway,v breathing, or
116. Prejudice is a hostile attitude toward circulation, then the nurse should evaluate the
individuals of a particular group. disease processes, giving priority to the disease
process that poses the greatest immediate risk.
 For example, if a patient has terminal cancer 152. Diseases that require strict isolation include
and hypoglycemia, hypoglycemia is a more chickenpox, diphtheria, and viral hemorrhagic
immediate concern. fevers such as Marburg disease.
134. E = Everything else. This category includes 153. For the patient who abides by Jewish
such issues as writing anv incident report and custom, milk and meat shouldn’t be served at
completing the patient chart. When evaluating the same meal.
needs, this category is never the highest 154. Whether the patient can perform a
priority. procedure (psychomotor domain ofv learning) is
135. Rule utilitarianism is known as the “greatest a better indicator of the effectiveness of patient
good for the greatest number of people” theory. teaching than whether the patient can simply
136. Egalitarian theory emphasizes that equal state the steps involved in the procedure
access to goods and servicesv must be provided (cognitive domain of learning).
to the less fortunate by an affluent society. 155. According to Erik Erikson, developmental
137. Before teaching any procedure to a patient, stages are trust versusv mistrust (birth to 18
the nurse must assess the patient’s current months), autonomy versus shame and doubt
knowledge and willingness to learn. (18 months to age 3), initiative versus guilt
138. Process recording is a method of evaluating (ages 3 to 5), industry versus inferiority (ages 5
one’s communication effectiveness. to 12), identity versus identity diffusion (ages 12
139. When feeding an elderly patient, the nurse to 18), intimacy versus isolation (ages 18 to 25),
should limit high-carbohydrate foods because of generativity versus stagnation (ages 25 to 60),
the risk of glucose intolerance. and ego integrity versus despair (older than age
140. When feeding an elderly patient, essential 60).
foods should be given first. 156. When communicating with a hearing
141. Passive range of motion maintains joint impaired patient, the nurse should face him.
mobility. Resistive exercises increase muscle 157. An appropriate nursing intervention for the
mass. spouse of a patient whov has a serious
142. Isometric exercises are performed on an incapacitating disease is to help him to mobilize
extremity that’s in a cast. a support system.
143. A back rub is an example of the gate-control 158. Hyperpyrexia is extreme elevation in
theory of pain. temperature above 106° F (41.1° C).
144. Anything that’s located below the waist is 159. Milk is high in sodium and low in iron.
considered unsterile; av sterile field becomes 160. When a patient expresses concern about a
unsterile when it comes in contact with any health-related issue, beforev addressing the
unsterile item; a sterile field must be monitored concern, the nurse should assess the patient’s
continuously; and a border of 1″ (2.5 cm) level of knowledge.
around a sterile field is considered unsterile. 161. The most effective way to reduce a fever is
145. A “shift to the left” is evident when the to administer an antipyretic, which lowers the
number of immature cells (bands) in the blood temperature set point.
increases to fight an infection. 162. Unlike false labor, true labor produces
146. A “shift to the right” is evident when the regular rhythmic contractions, abdominal
number of mature cells inv the blood increases, discomfort, progressive descent of the fetus,
as seen in advanced liver disease and pernicious bloody show, and progressive effacement and
anemia. dilation of the cervix.
147. Before administering preoperative 163. To help a mother break the suction of her
medication, the nurse should ensurev that an breast-feeding infant, the nurse should teach
informed consent form has been signed and her to insert a finger at the corner of the
attached to the patient’s record. infant’s mouth.
148. A nurse should spend no more than 30 164. Administering high levels of oxygen to a
minutes per 8-hour shift providing care to a premature neonate can cause blindness as a
patient who has a radiation implant. result of retrolental fibroplasia.
149. A nurse shouldn’t be assigned to care for 165. Amniotomy is artificial rupture of the
more than one patient who has a radiation amniotic membranes.
implant. 166. During pregnancy, weight gain averages 25
150. Long-handled forceps and a lead-lined to 30 lb (11 to 13.5 kg).
container should be available in the room of a 167. Rubella has a teratogenic effect on the fetus
patient who has a radiation implant. during the first trimester. It produces
151. Usually, patients who have the same abnormalities in up to 40% of cases without
infection and are in strict isolation can share a interrupting the pregnancy.
room. 168. Immunity to rubella can be measured by a
hemagglutination inhibition test (rubella titer).
 This test identifies exposure to rubella infection 183. To estimate the date of delivery using
and determines susceptibility in pregnant Nägele’s rule, the nurse counts backward 3
women. In a woman, a titer greater than 1:8 months from the first day of the last menstrual
indicates immunity. period and then adds 7 days to this date.
169. When used to describe the degree of fetal 184. At 12 weeks’ gestation, the fundus should be
descent during labor, floating means the at the top of the symphysis pubis.
presenting part isn’t engaged in the pelvic inlet, 185. Cow’s milk shouldn’t be given to infants
but is freely movable (ballotable) above the younger than age 1 because it has a low linoleic
pelvic inlet. acid content and its protein is difficult for infants
170. When used to describe the degree of fetal to digest.
descent, engagement means when the largest 186. If jaundice is suspected in a neonate, the
diameter of the presenting part has passed nurse should examine the infant under natural
through the pelvic inlet. window light. If natural light is unavailable, the
171. Fetal station indicates the location of the nurse should examine the infant under a white
presenting part in relation to the ischial spine. light.
It’s described as –1, –2, –3, –4, or –5 to 187. The three phases of a uterine contraction
indicate the number of centimeters above the are increment, acme, and decrement.
level of the ischial spine; station –5 is at the 188. The intensity of a labor contraction can be
pelvic inlet. assessed by the indentability of the uterine wall
172. Fetal station also is described as +1, +2, +3, at the contraction’s peak. Intensity is graded as
+4, or +5 to indicate the number of centimeters mild (uterine muscle is somewhat tense),
it is below the level of the ischial spine; station moderate (uterine muscle is moderately tense),
0 is at the level of the ischial spine. or strong (uterine muscle is boardlike).
173. During the first stage of labor, the side-lying 189. Chloasma, the mask of pregnancy, is
position usually provides the greatest degree of pigmentation of a circumscribed area of skin
comfort, although the patient may assume any (usually over the bridge of the nose and cheeks)
comfortable position. that occurs in some pregnant women.
174. During delivery, if the umbilical cord can’t be 190. The gynecoid pelvis is most ideal for
loosened and slipped from around the neonate’s delivery. Other types include platypelloid (flat),
neck, it should be clamped with two clamps and anthropoid (apelike), and android (malelike).
cut between the clamps. 191. Pregnant women should be advised that
175. An Apgar score of 7 to 10 indicates no there is no safe level of alcohol intake.
immediate distress, 4 to 6 indicates moderate 192. The frequency of uterine contractions, which
distress, and 0 to 3 indicates severe distress. is measured in minutes, is the time from the
176. To elicit Moro’s reflex, the nurse holds the beginning of one contraction to the beginning of
neonate in both hands and suddenly, but gently, the next.
drops the neonate’s head backward. Normally, 193. Vitamin K is administered to neonates to
the neonate abducts and extends all extremities prevent hemorrhagic disorders because a
bilaterally and symmetrically, forms a C shape neonate’s intestine can’t synthesize vitamin K.
with the thumb and forefinger, and first adducts 194. Before internal fetal monitoring can be
and then flexes the extremities. performed, a pregnant patient’s cervix must be
177. Pregnancy-induced hypertension dilated at least 2 cm, the amniotic membranes
(preeclampsia) is an increase in blood pressure must be ruptured, and the fetus’s presenting
of 30/15 mm Hg over baseline or blood pressure part (scalp or buttocks) must be at station –1 or
of 140/95 mm Hg on two occasions at least 6 lower, so that a small electrode can be
hours apart accompanied by edema and attached.
albuminuria after 20 weeks’ gestation. 195. Fetal alcohol syndrome presents in the first
178. Positive signs of pregnancy include 24 hours after birth and produces lethargy,
ultrasound evidence, fetal heart tones, and fetal seizures, poor sucking reflex, abdominal
movement felt by the examiner (not usually distention, and respiratory difficulty.
present until 4 months’ gestation) 196. Variability is any change in the fetal heart
179. Goodell’s sign is softening of the cervix. rate (FHR) from its normal rate of 120 to 160
180. Quickening, a presumptive sign of beats/minute. Acceleration is increased FHR;
pregnancy, occurs between 16 and 19 weeks’ deceleration is decreased FHR.
gestation. 197. In a neonate, the symptoms of heroin
181. Ovulation ceases during pregnancy. withdrawal may begin several hours to 4 days
182. Any vaginal bleeding during pregnancy after birth.
should be considered a complication until 198. In a neonate, the symptoms of methadone
proven otherwise. withdrawal may begin 7 days to several weeks
after birth.
199. In a neonate, the cardinal signs of narcotic neonates have heel creases that cover less than
withdrawal include coarse, flapping tremors; two-thirds of the feet.
sleepiness; restlessness; prolonged, persistent, 219. The fourth stage of labor (postpartum
high-pitched cry; and irritability. stabilization) lasts up to 4 hours after the
200. The nurse should count a neonate’s placenta is delivered. This time is needed to
respirations for 1 full minute. stabilize the mother’s physical and emotional
201. Chlorpromazine (Thorazine) is used to treat state after the stress of childbirth.
neonates who are addicted to narcotics. 220. At 20 weeks’ gestation, the fundus is at the
202. The nurse should provide a dark, quiet level of the umbilicus.
environment for a neonate who is experiencing 221. At 36 weeks’ gestation, the fundus is at the
narcotic withdrawal. lower border of the rib cage.
203. In a premature neonate, signs of respiratory 222. A premature neonate is one born before the
distress include nostril flaring, substernal end of the 37th week of gestation.
retractions, and inspiratory grunting. 223. Pregnancy-induced hypertension is a leading
204. Respiratory distress syndrome (hyaline cause of maternal death in the United States.
membrane disease) develops in premature 224. A habitual aborter is a woman who has had
infants because their pulmonary alveoli lack three or more consecutive spontaneous
surfactant. abortions.
205. Whenever an infant is being put down to 225. Threatened abortion occurs when bleeding is
sleep, the parent or caregiver should position present without cervical dilation.
the infant on the back. (Remember back to 226. A complete abortion occurs when all
sleep.) products of conception are expelled.
206. The male sperm contributes an X or a Y 227. Hydramnios (polyhydramnios) is excessive
chromosome; the female ovum contributes an X amniotic fluid (more than 2,000 ml in the third
chromosome. trimester).
207. Fertilization produces a total of 46 228. Stress, dehydration, and fatigue may reduce
chromosomes, including an XY combination a breast-feeding mother’s milk supply.
(male) or an XX combination (female). 229. During the transition phase of the first stage
208. The percentage of water in a neonate’s body of labor, the cervix is dilated 8 to 10 cm and
is about 78% to 80%. contractions usually occur 2 to 3 minutes apart
209. To perform nasotracheal suctioning in an and last for 60 seconds.
infant, the nurse positions the infant with his 230. A nonstress test is considered nonreactive
neck slightly hyperextended in a “sniffing” (positive) if fewer than two fetal heart rate
position, with his chin up and his head tilted accelerations of at least 15 beats/minute occur
back slightly. in 20 minutes.
210. Organogenesis occurs during the first 231. A nonstress test is considered reactive
trimester of pregnancy, specifically, days 14 to (negative) if two or more fetal heart rate
56 of gestation. accelerations of 15 beats/minute above baseline
211. After birth, the neonate’s umbilical cord is occur in 20 minutes.
tied 1″ (2.5 cm) from the abdominal wall with a 232. A nonstress test is usually performed to
cotton cord, plastic clamp, or rubber band. assess fetal well-being in a pregnant patient
212. Gravida is the number of pregnancies a with a prolonged pregnancy (42 weeks or
woman has had, regardless of outcome. more), diabetes, a history of poor pregnancy
213. Para is the number of pregnancies that outcomes, or pregnancy-induced hypertension.
reached viability, regardless of whether the 233. A pregnant woman should drink at least
fetus was delivered alive or stillborn. A fetus is eight 8-oz glasses (about 2,000 ml) of water
considered viable at 20 weeks’ gestation. daily.
214. An ectopic pregnancy is one that implants 234. When both breasts are used for breast-
abnormally, outside the uterus. feeding, the infant usually doesn’t empty the
215. The first stage of labor begins with the onset second breast. Therefore, the second breast
of labor and ends with full cervical dilation at 10 should be used first at the next feeding.
cm. 235. A low-birth-weight neonate weighs 2,500 g
216. The second stage of labor begins with full (5 lb 8 oz) or less at birth.
cervical dilation and ends with the neonate’s 236. A very-low-birth-weight neonate weighs
birth. 1,500 g (3 lb 5 oz) or less at birth.
217. The third stage of labor begins after the 237. When teaching parents to provide umbilical
neonate’s birth and ends with expulsion of the cord care, the nurse should teach them to clean
placenta. the umbilical area with a cotton ball saturated
218. In a full-term neonate, skin creases appear with alcohol after every diaper change to
over two-thirds of the neonate’s feet. Preterm prevent infection and promote drying.
238. Teenage mothers are more likely to have 253. Eclampsia is the occurrence of seizures that
low-birth-weight neonates because they seek aren’t caused by a cerebral disorder in a patient
prenatal care late in pregnancy (as a result of who has pregnancy-induced hypertension.
denial) and are more likely than older mothers 254. In placenta previa, bleeding is painless and
to have nutritional deficiencies. seldom fatal on the first occasion, but it
239. Linea nigra, a dark line that extends from becomes heavier with each subsequent episode.
the umbilicus to the mons pubis, commonly 255. Treatment for abruptio placentae is usually
appears during pregnancy and disappears after immediate cesarean delivery.
pregnancy. 256. Drugs used to treat withdrawal symptoms in
240. Implantation in the uterus occurs 6 to 10 neonates include phenobarbital (Luminal),
days after ovum fertilization. camphorated opium tincture (paregoric), and
241. Placenta previa is abnormally low diazepam (Valium).
implantation of the placenta so that it 257. Infants with Down syndrome typically have
encroaches on or covers the cervical os. marked hypotonia, floppiness, slanted eyes,
242. In complete (total) placenta previa, the excess skin on the back of the neck, flattened
placenta completely covers the cervical os. bridge of the nose, flat facial features, spadelike
243. In partial (incomplete or marginal) placenta hands, short and broad feet, small male
previa, the placenta covers only a portion of the genitalia, absence of Moro’s reflex, and a simian
cervical os. crease on the hands.
244. Abruptio placentae is premature separation 258. The failure rate of a contraceptive is
of a normally implanted placenta. It may be determined by the experience of 100 women for
partial or complete, and usually causes 1 year. It’s expressed as pregnancies per 100
abdominal pain, vaginal bleeding, and a woman-years.
boardlike abdomen. 259. The narrowest diameter of the pelvic inlet is
245. Cutis marmorata is mottling or purple the anteroposterior (diagonal conjugate).
discoloration of the skin. It’s a transient 260. The chorion is the outermost extraembryonic
vasomotor response that occurs primarily in the membrane that gives rise to the placenta.
arms and legs of infants who are exposed to 261. The corpus luteum secretes large quantities
cold. of progesterone.
246. The classic triad of symptoms of 262. From the 8th week of gestation through
preeclampsia are hypertension, edema, and delivery, the developing cells are known as a
proteinuria. Additional symptoms of severe fetus.
preeclampsia include hyperreflexia, cerebral and 263. In an incomplete abortion, the fetus is
vision disturbances, and epigastric pain. expelled, but parts of the placenta and
247. Ortolani’s sign (an audible click or palpable membrane remain in the uterus.
jerk that occurs with thigh abduction) confirms 264. The circumference of a neonate’s head is
congenital hip dislocation in a neonate. normally 2 to 3 cm greater than the
248. The first immunization for a neonate is the circumference of the chest.
hepatitis B vaccine, which is administered in the 265. After administering magnesium sulfate to a
nursery shortly after birth. pregnant patient for hypertension or preterm
249. If a patient misses a menstrual period while labor, the nurse should monitor the respiratory
taking an oral contraceptive exactly as rate and deep tendon reflexes.
prescribed, she should continue taking the 266. During the first hour after birth (the period
contraceptive. of reactivity), the neonate is alert and awake.
250. If a patient misses two consecutive 267. When a pregnant patient has undiagnosed
menstrual periods while taking an oral vaginal bleeding, vaginal examination should be
contraceptive, she should discontinue the avoided until ultrasonography rules out placenta
contraceptive and take a pregnancy test. previa.
251. If a patient who is taking an oral 268. After delivery, the first nursing action is to
contraceptive misses a dose, she should take establish the neonate’s airway.
the pill as soon as she remembers or take two 269. Nursing interventions for a patient with
at the next scheduled interval and continue with placenta previa include positioning the patient
the normal schedule. on her left side for maximum fetal perfusion,
252. If a patient who is taking an oral monitoring fetal heart tones, and administering
contraceptive misses two consecutive doses, I.V. fluids and oxygen, as ordered.
she should double the dose for 2 days and then 270. The specific gravity of a neonate’s urine is
resume her normal schedule. She also should 1.003 to 1.030. A lower specific gravity suggests
use an additional birth control method for 1 overhydration; a higher one suggests
week. dehydration.
271. The neonatal period extends from birth to fetal status is suspected, fetal blood pH may be
day 28. It’s also called the first 4 weeks or first evaluated by obtaining a scalp sample.
month of life. 288. In an emergency delivery, enough pressure
272. A woman who is breast-feeding should rub a should be applied to the emerging fetus’s head
mild emollient cream or a few drops of breast to guide the descent and prevent a rapid
milk (or colostrum) on the nipples after each change in pressure within the molded fetal skull.
feeding. She should let the breasts air-dry to 289. After delivery, a multiparous woman is more
prevent them from cracking. susceptible to bleeding than a primiparous
273. Breast-feeding mothers should increase their woman because her uterine muscles may be
fluid intake to 2½ to 3 qt (2,500 to 3,000 ml) overstretched and may not contract efficiently.
daily. 290. Neonates who are delivered by cesarean
274. After feeding an infant with a cleft lip or birth have a higher incidence of respiratory
palate, the nurse should rinse the infant’s mouth distress syndrome.
with sterile water. 291. The nurse should suggest ambulation to a
275. The nurse instills erythromycin in a neonate’s postpartum patient who has gas pain and
eyes primarily to prevent blindness caused by flatulence.
gonorrhea or chlamydia. 292. Massaging the uterus helps to stimulate
276. Human immunodeficiency virus (HIV) has contractions after the placenta is delivered.
been cultured in breast milk and can be 293. When providing phototherapy to a neonate,
transmitted by an HIV-positive mother who the nurse should cover the neonate’s eyes and
breast-feeds her infant. genital area.
277. A fever in the first 24 hours postpartum is 294. The narcotic antagonist naloxone (Narcan)
most likely caused by dehydration rather than may be given to a neonate to correct respiratory
infection. depression caused by narcotic administration to
278. Preterm neonates or neonates who can’t the mother during labor.
maintain a skin temperature of at least 97.6° F 295. In a neonate, symptoms of respiratory
(36.4° C) should receive care in an incubator distress syndrome include expiratory grunting or
(Isolette) or a radiant warmer. In a radiant whining, sandpaper breath sounds, and seesaw
warmer, a heat-sensitive probe taped to the retractions.
neonate’s skin activates the heater unit 296. Cerebral palsy presents as asymmetrical
automatically to maintain the desired movement, irritability, and excessive, feeble
temperature. crying in a long, thin infant.
279. During labor, the resting phase between 297. The nurse should assess a breech-birth
contractions is at least 30 seconds. neonate for hydrocephalus, hematomas,
280. Lochia rubra is the vaginal discharge of fractures, and other anomalies caused by birth
almost pure blood that occurs during the first trauma.
few days after childbirth. 298. When a patient is admitted to the unit in
281. Lochia serosa is the serous vaginal discharge active labor, the nurse’s first action is to listen
that occurs 4 to 7 days after childbirth. for fetal heart tones.
282. Lochia alba is the vaginal discharge of 299. In a neonate, long, brittle fingernails are a
decreased blood and increased leukocytes that’s sign of postmaturity.
the final stage of lochia. It occurs 7 to 10 days 300. Desquamation (skin peeling) is common in
after childbirth. postmature neonates.
283. Colostrum, the precursor of milk, is the first 301. A mother should allow her infant to breast-
secretion from the breasts after delivery. feed until the infant is satisfied. The time may
284. The length of the uterus increases from 2½” vary from 5 to 20 minutes.
(6.3 cm) before pregnancy to 12½” (32 cm) at 302. Nitrazine paper is used to test the pH of
term. vaginal discharge to determine the presence of
285. To estimate the true conjugate (the smallest amniotic fluid.
inlet measurement of the pelvis), deduct 1.5 cm 303. A pregnant patient normally gains 2 to 5 lb
from the diagonal conjugate (usually 12 cm). A (1 to 2.5 kg) during the first trimester and
true conjugate of 10.5 cm enables the fetal slightly less than 1 lb (0.5 kg) per week during
head (usually 10 cm) to pass. the last two trimesters.
286. The smallest outlet measurement of the 304. Neonatal jaundice in the first 24 hours after
pelvis is the intertuberous diameter, which is the birth is known as pathological jaundice and is a
transverse diameter between the ischial sign of erythroblastosis fetalis.
tuberosities. 305. A classic difference between abruptio
287. Electronic fetal monitoring is used to assess placentae and placenta previa is the degree of
fetal well-being during labor. If compromised pain. Abruptio placentae causes pain, whereas
placenta previa causes painless bleeding.
306. Because a major role of the placenta is to must be administered under close observation
function as a fetal lung, any condition that to help prevent maternal and fetal distress.
interrupts normal blood flow to or from the 323. During fetal heart rate monitoring, variable
placenta increases fetal partial pressure of decelerations indicate compression or prolapse
arterial carbon dioxide and decreases fetal pH. of the umbilical cord.
307. Precipitate labor lasts for approximately 3 324. Cytomegalovirus is the leading cause of
hours and ends with delivery of the neonate congenital viral infection.
308. Methylergonovine (Methergine) is an 325. Tocolytic therapy is indicated in premature
oxytocic agent used to prevent and treat labor, but contraindicated in fetal death, fetal
postpartum hemorrhage caused by uterine distress, or severe hemorrhage.
atony or subinvolution. 326. Through ultrasonography, the biophysical
309. As emergency treatment for excessive profile assesses fetal well-being by measuring
uterine bleeding, 0.2 mg of methylergonovine fetal breathing movements, gross body
(Methergine) is injected I.V. over 1 minute while movements, fetal tone, reactive fetal heart rate
the patient’s blood pressure and uterine (nonstress test), and qualitative amniotic fluid
contractions are monitored. volume.
310. Braxton Hicks contractions are usually felt in 327. A neonate whose mother has diabetes
the abdomen and don’t cause cervical change. should be assessed for hyperinsulinism.
True labor contractions are felt in the front of 328. In a patient with preeclampsia, epigastric
the abdomen and back and lead to progressive pain is a late symptom and requires immediate
cervical dilation and effacement. medical intervention.
311. The average birth weight of neonates born 329. After a stillbirth, the mother should be
to mothers who smoke is 6 oz (170 g) less than allowed to hold the neonate to help her come to
that of neonates born to nonsmoking mothers. terms with the death.
312. Culdoscopy is visualization of the pelvic 330. Molding is the process by which the fetal
organs through the posterior vaginal fornix. head changes shape to facilitate movement
313. The nurse should teach a pregnant through the birth canal.
vegetarian to obtain protein from alternative 331. If a woman receives a spinal block before
sources, such as nuts, soybeans, and legumes. delivery, the nurse should monitor the patient’s
314. The nurse should instruct a pregnant patient blood pressure closely.
to take only prescribed prenatal vitamins 332. If a woman suddenly becomes hypotensive
because over-the-counter high-potency vitamins during labor, the nurse should increase the
may harm the fetus. infusion rate of I.V. fluids as prescribed.
315. High-sodium foods can cause fluid retention, 333. The best technique for assessing jaundice in
especially in pregnant patients. a neonate is to blanch the tip of the nose or the
316. A pregnant patient can avoid constipation area just above the umbilicus.
and hemorrhoids by adding fiber to her diet. 334. During fetal heart monitoring, early
317. If a fetus has late decelerations (a sign of deceleration is caused by compression of the
fetal hypoxia), the nurse should instruct the head during labor.
mother to lie on her left side and then 335. After the placenta is delivered, the nurse
administer 8 to 10 L of oxygen per minute by may add oxytocin (Pitocin) to the patient’s I.V.
mask or cannula. The nurse should notify the solution, as prescribed, to promote postpartum
physician. The side-lying position removes involution of the uterus and stimulate lactation.
pressure on the inferior vena cava. 336. Pica is a craving to eat nonfood items, such
318. Oxytocin (Pitocin) promotes lactation and as dirt, crayons, chalk, glue, starch, or hair. It
uterine contractions. may occur during pregnancy and can endanger
319. Lanugo covers the fetus’s body until about the fetus.
20 weeks’ gestation. Then it begins to disappear 337. A pregnant patient should take folic acid
from the face, trunk, arms, and legs, in that because this nutrient is required for rapid cell
order. division.
320. In a neonate, hypoglycemia causes 338. A woman who is taking clomiphene (Clomid)
temperature instability, hypotonia, jitteriness, to induce ovulation should be informed of the
and seizures. Premature, postmature, small-for- possibility of multiple births with this drug.
gestational-age, and large-for-gestational-age 339. If needed, cervical suturing is usually done
neonates are susceptible to this disorder. between 14 and 18 weeks’ gestation to
321. Neonates typically need to consume 50 to 55 reinforce an incompetent cervix and maintain
cal per pound of body weight daily. pregnancy. The suturing is typically removed by
322. Because oxytocin (Pitocin) stimulates 35 weeks’ gestation.
powerful uterine contractions during labor, it
340. During the first trimester, a pregnant woman 4. The union of a male and a female gamete
should avoid all drugs unless doing so would produces a zygote, which divides into the
adversely affect her health. fertilized ovum.
341. Most drugs that a breast-feeding mother 5. The first menstrual flow is called menarche
takes appear in breast milk. and may be anovulatory (infertile).
342. The Food and Drug Administration has 6. Spermatozoa (or their fragments) remain in
established the following five categories of the vagina for 72 hours after sexual intercourse.
drugs based on their potential for causing birth 7. Prolactin stimulates and sustains milk
defects: A, no evidence of risk; B, no risk found productions
in animals, but no studies have been done in 8. Strabismus is a normal finding in a neonate.
women; C, animal studies have shown an 9. A postpartum patient may resume sexual
adverse effect, but the drug may be beneficial intercourse after the perineal or uterine wounds
to women despite the potential risk; D, evidence heal (usually within 4 weeks after delivery).
of risk, but its benefits may outweigh its risks; 10. A pregnant staff member shouldn’t be
and X, fetal anomalies noted, and the risks assigned to work with a patient who has
clearly outweigh the potential benefits. cytomegalovirus infection because the virus can
343. A patient with a ruptured ectopic pregnancy be transmitted to the fetus.
commonly has sharp pain in the lower 11. Fetal demise is death of the fetus after
abdomen, with spotting and cramping. She may viability.
have abdominal rigidity; rapid, shallow 12. Respiratory distress syndrome develops in
respirations; tachycardia; and shock. premature neonates because their alveoli lack
344. A patient with a ruptured ectopic pregnancy surfactant
commonly has sharp pain in the lower 13. The most common method of inducing labor
abdomen, with spotting and cramping. She may after artificial rupture of the membranes is
have abdominal rigidity; rapid, shallow oxytocin (Pitocin) infusion.
respirations; tachycardia; and shock. 14. After the amniotic membranes rupture, the
345. The mechanics of delivery are engagement, initial nursing action is to assess the fetal heart
descent and flexion, internal rotation, extension, rate.
external rotation, restitution, and expulsion. 15. The most common reasons for cesarean
346. A probable sign of pregnancy, McDonald’s birth are malpresentation, fetal distress,
sign is characterized by an ease in flexing the cephalopelvic disproportion, pregnancy-induced
body of the uterus against the cervix. hypertension, previous cesarean birth, and
347. Amenorrhea is a probable sign of pregnancy. inadequate progress in labor.
348. A pregnant woman’s partner should avoid 16. Amniocentesis increases the risk of
introducing air into the vagina during oral sex spontaneous abortion, trauma to the fetus or
because of the possibility of air embolism. placenta, premature labor, infection, and Rh
349. The presence of human chorionic sensitization of the fetus.
gonadotropin in the blood or urine is a probable 17. After amniocentesis, abdominal cramping or
sign of pregnancy. spontaneous vaginal bleeding may indicate
350. Radiography isn’t usually used in a pregnant complications.
woman because it may harm the developing 18. To prevent her from developing Rh
fetus. If radiography is essential, it should be antibodies, an Rh-negative primigravida should
performed only after 36 weeks’ gestation. receive Rho(D) immune globulin (RhoGAM) after
delivering an Rh-positive neonate.
19. If a pregnant patient’s test results are
MEDSURG II negative for glucose but positive for acetone,
the nurse should assess the patient’s diet for
inadequate caloric intake.
Go!
20. If a pregnant patient’s test results are
negative for glucose but positive for acetone,
1. A pregnant patient who has had rupture of
the nurse should assess the patient’s diet for
the membranes or who is experiencing vaginal
inadequate caloric intake.
bleeding shouldn’t engage in sexual intercourse.
21. Rubella infection in a pregnant patient,
2. Milia may occur as pinpoint spots over a
especially during the first trimester, can lead to
neonate’s nose.
spontaneous abortion or stillbirth as well as fetal
3. The duration of a contraction is timed from
cardiac and other birth defects.
the moment that the uterine muscle begins to
22. A pregnant patient should take an iron
tense to the moment that it reaches full
supplement to help prevent anemia.
relaxation. It’s measured in seconds.
23. Direct antiglobulin (direct Coombs’) test is 38. The patient with preeclampsia usually has
used to detect maternal antibodies attached to puffiness around the eyes or edema in the
red blood cells in the neonate. hands (for example, “I can’t put my wedding
24. Nausea and vomiting during the first ring on.”).
trimester of pregnancy are caused by rising 39. Kegel exercises require contraction and
levels of the hormone human chorionic relaxation of the perineal muscles. These
gonadotropin. exercises help strengthen pelvic muscles and
25. Before discharging a patient who has had an improve urine control in postpartum patients.
abortion, the nurse should instruct her to report 40. Symptoms of postpartum depression range
bright red clots, bleeding that lasts longer than from mild postpartum blues to intense, suicidal,
7 days, or signs of infection, such as a depressive psychosis.
temperature of greater than 100° F (37.8° C), 41. The preterm neonate may require gavage
foul-smelling vaginal discharge, severe uterine feedings because of a weak sucking reflex,
cramping, nausea, or vomiting. uncoordinated sucking, or respiratory distress.
26. When informed that a patient’s amniotic 42. Acrocyanosis (blueness and coolness of the
membrane has broken, the nurse should check arms and legs) is normal in neonates because of
fetal heart tones and then maternal vital signs. their immature peripheral circulatory system.
27. The duration of pregnancy averages 280 43. To prevent ophthalmia neonatorum (a
days, 40 weeks, 9 calendar months, or 10 lunar severe eye infection caused by maternal
months. gonorrhea), the nurse may administer one of
28. The initial weight loss for a healthy neonate three drugs, as prescribed, in the neonate’s
is 5% to 10% of birth weight. eyes: tetracycline, silver nitrate, or
29. The normal hemoglobin value in neonates is erythromycin.
17 to 20 g/dl. 44. Neonatal testing for phenylketonuria is
30. Crowning is the appearance of the fetus’s mandatory in most states.
head when its largest diameter is encircled by 45. The nurse should place the neonate in a 30-
the vulvovaginal ring. degree Trendelenburg position to facilitate
31. A multipara is a woman who has had two or mucus drainage.
more pregnancies that progressed to viability, 46. The nurse may suction the neonate’s nose
regardless of whether the offspring were alive at and mouth as needed with a bulb syringe or
birth. suction trap.
32. In a pregnant patient, preeclampsia may 47. To prevent heat loss, the nurse should place
progress to eclampsia, which is characterized by the neonate under a radiant warmer during
seizures and may lead to coma. suctioning and initial delivery-room care, and
33. The Apgar score is used to assess the then wrap the neonate in a warmed blanket for
neonate’s vital functions. It’s obtained at 1 transport to the nursery.
minute and 5 minutes after delivery. The score 48. The umbilical cord normally has two arteries
is based on respiratory effort, heart rate, muscle and one vein.
tone, reflex irritability, and color. 49. When providing care, the nurse should
34. Because of the anti-insulin effects of expose only one part of an infant’s body at a
placental hormones, insulin requirements time.
increase during the third trimester. 50. Lightening is settling of the fetal head into
35. Gestational age can be estimated by the brim of the pelvis.
ultrasound measurement of maternal abdominal 51. The nurse must place identification bands on
circumference, fetal femur length, and fetal both the mother and the neonate before they
head size. These measurements are most leave the delivery room.
accurate between 12 and 18 weeks’ gestation. 52. Erythromycin is given at birth to prevent
36. Skeletal system abnormalities and ventricular ophthalmia neonatorum.
septal defects are the most common disorders 53. Pelvic-tilt exercises can help to prevent or
of infants who are born to diabetic women. The relieve backache during pregnancy.
incidence of congenital malformation is three 54. Before performing a Leopold maneuver, the
times higher in these infants than in those born nurse should ask the patient to empty her
to nondiabetic women. bladder.
37. Skeletal system abnormalities and ventricular 55. If the neonate is stable, the mother should
septal defects are the most common disorders be allowed to breast-feed within the neonate’s
of infants who are born to diabetic women. The first hour of life.
incidence of congenital malformation is three 56. The nurse should check the neonate’s
times higher in these infants than in those born temperature every 1 to 2 hours until it’s
to nondiabetic women. maintained within normal limits.
57. At birth, a neonate normally weighs 5 to 9 lb 72. The Guthrie test (a screening test for
(2 to 4 kg), measures 18″ to 22″ (45.5 to 56 phenylketonuria) is most reliable if it’s done
cm) in length, has a head circumference of between the second and sixth days after birth
13½” to 14″ (34 to 35.5 cm), and has a chest and is performed after the neonate has ingested
circumference that’s 1″ (2.5 cm) less than the protein.
head circumference. 73. To assess coordination of sucking and
58. In the neonate, temperature normally ranges swallowing, the nurse should observe the
from 98° to 99° F (36.7° to 37.2° neonate’s first breast-feeding or sterile water
C), apical pulse rate averages 120 to 160 bottle-feeding.
beats/minute, and respirations are 40 to 60 74. To establish a milk supply pattern, the
breaths/minute. mother should breast-feed her infant at least
59. The diamond-shaped anterior fontanel every 4 hours. During the first month, she
usually closes between ages 12 and 18 months. should breast-feed 8 to 12 times daily (demand
The triangular posterior fontanel usually closes feeding).
by age 2 months. 75. To avoid contact with blood and other body
60. In the neonate, a straight spine is normal. A fluids, the nurse should wear gloves when
tuft of hair over the spine is an abnormal handling the neonate until after the first bath is
finding. given.
61. Prostaglandin gel may be applied to the 76. If a breast-fed infant is content, has good
vagina or cervix to ripen an unfavorable cervix skin turgor, an adequate number of wet diapers,
before labor induction with oxytocin (Pitocin) and normal weight gain, the mother’s milk
62. Supernumerary nipples are occasionally seen supply is assumed to be adequate.
on neonates. They usually appear along a line 77. In the supine position, a pregnant patient’s
that runs from each axilla, through the normal enlarged uterus impairs venous return from the
nipple area, and to the groin. lower half of the body to the heart, resulting in
63. Meconium is a material that collects in the supine hypotensive syndrome, or inferior vena
fetus’s intestines and forms the neonate’s first cava syndrome.
feces, which are black and tarry. 78. Tocolytic agents used to treat preterm labor
64. The presence of meconium in the amniotic include terbutaline (Brethine), ritodrine
fluid during labor indicates possible fetal distress (Yutopar), and magnesium sulfate.
and the need to evaluate the neonate for 79. A pregnant woman who has hyperemesis
meconium aspiration. gravidarum may require hospitalization to treat
65. To assess a neonate’s rooting reflex, the dehydration and starvation.
nurse touches a finger to the cheek or the 80. Diaphragmatic hernia is one of the most
corner of the mouth. Normally, the neonate urgent neonatal surgical emergencies. By
turns his head toward the stimulus, opens his compressing and displacing the lungs and heart,
mouth, and searches for the stimulus. this disorder can cause respiratory distress
66. Harlequin sign is present when a neonate shortly after birth.
who is lying on his side appears red on the 81. Common complications of early pregnancy
dependent side and pale on the upper side. (up to 20 weeks’ gestation) include fetal loss
67. Mongolian spots can range from brown to and serious threats to maternal health.
blue. Their color depends on how close 82. Fetal embodiment is a maternal
melanocytes are to the surface of the skin. They developmental task that occurs in the second
most commonly appear as patches across the trimester. During this stage, the mother may
sacrum, buttocks, and legs. complain that she never gets to sleep because
68. Mongolian spots are common in non-white the fetus always gives her a thump when she
infants and usually disappear by age 2 to 3 tries.
years. 83. Visualization in pregnancy is a process in
69. Vernix caseosa is a cheeselike substance that which the mother imagines what the child she’s
covers and protects the fetus’s skin in utero. It carrying is like and becomes acquainted with it.
may be rubbed into the neonate’s skin or 84. Hemodilution of pregnancy is the increase in
washed away in one or two baths. blood volume that occurs during pregnancy. The
70. Caput succedaneum is edema that develops increased volume consists of plasma and causes
in and under the fetal scalp during labor and an imbalance between the ratio of red blood
delivery. It resolves spontaneously and presents cells to plasma and a resultant decrease in
no danger to the neonate. The edema doesn’t hematocrit.
cross the suture line. 85. Mean arterial pressure of greater than 100
71. Nevus flammeus, or port-wine stain, is a mm Hg after 20 weeks of pregnancy is
diffuse pink to dark bluish red lesion on a considered hypertension.
neonate’s face or neck.
86. The treatment for supine hypotension 105. Implantation occurs when the cellular walls
syndrome (a condition that sometimes occurs in of the blastocyte implants itself in the
pregnancy) is to have the patient lie on her left endometrium, usually 7 to 9 days after
side. fertilization.
87. A contributing factor in dependent edema in 106. Implantation occurs when the cellular walls
the pregnant patient is the increase of femoral of the blastocyte implants itself in the
venous pressure from 10 mm Hg (normal) to 18 endometrium, usually 7 to 9 days after
mm Hg (high). fertilization.
88. An estriol level is used to assess fetal well- 107. Heart development in the embryo begins at
being and maternal renal functioning as well as 2 to 4 weeks and is complete by the end of the
to monitor a pregnancy that’s complicated by embryonic stage.
diabetes. 108. Methergine stimulates uterine contractions.
89. A pregnant patient with vaginal bleeding 109. The administration of folic acid during the
shouldn’t have a pelvic examination. early stages of gestation may prevent neural
90. In the early stages of pregnancy, the finding tube defects.
of glucose in the urine may be related to the 110. With advanced maternal age, a common
increased shunting of glucose to the developing genetic problem is Down syndrome.
placenta, without a corresponding increase in 111. With early maternal age, cephalopelvic
the reabsorption capability of the kidneys. disproportion commonly occurs.
91. A patient who has premature rupture of the 112. In the early postpartum period, the fundus
membranes is at significant risk for infection if should be midline at the umbilicus.
labor doesn’t begin within 24 hours. 113. A rubella vaccine shouldn’t be given to a
92. Infants of diabetic mothers are susceptible pregnant woman. The vaccine can be
to macrosomia as a result of increased insulin administered after delivery, but the patient
production in the fetus. should be instructed to avoid becoming
93. To prevent heat loss in the neonate, the pregnant for 3 months.
nurse should bathe one part of his body at a 114. A 16-year-old girl who is pregnant is at risk
time and keep the rest of the body covered. for having a low-birth-weight neonate.
94. A patient who has a cesarean delivery is at 115. The mother’s Rh factor should be
greater risk for infection than the patient who determined before an amniocentesis is
gives birth vaginally. performed.
95. The occurrence of thrush in the neonate is 116. Maternal hypotension is a complication of
probably caused by contact with the organism spinal block.
during delivery through the birth canal. 117. After delivery, if the fundus is boggy and
96. The nurse should keep the sac of deviated to the right side, the patient should
meningomyelocele moist with normal saline empty her bladder.
solution. 118. Before providing a specimen for a sperm
97. If fundal height is at least 2 cm less than count, the patient should avoid ejaculation for
expected, the cause may be growth retardation, 48 to 72 hours.
missed abortion, transverse lie, or false 119. The hormone human chorionic gonadotropin
pregnancy. is a marker for pregnancy.
98. Fundal height that exceeds expectations by 120. Painless vaginal bleeding during the last
more than 2 cm may be caused by multiple trimester of pregnancy may indicate placenta
gestation, polyhydramnios, uterine myomata, or previa.
a large baby. 121. During the transition phase of labor, the
99. A major developmental task for a woman woman usually is irritable and restless.
during the first trimester of pregnancy is 122. Because women with diabetes have a higher
accepting the pregnancy. incidence of birth anomalies than women
100. Unlike formula, breast milk offers the benefit without diabetes, an alpha-fetoprotein level may
of maternal antibodies. be ordered at 15 to 17 weeks’ gestation.
101. Spontaneous rupture of the membranes 123. To avoid puncturing the placenta, a vaginal
increases the risk of a prolapsed umbilical cord. examination shouldn’t be performed on a
102. A clinical manifestation of a prolapsed pregnant patient who is bleeding.
umbilical cord is variable decelerations. 124. A patient who has postpartum hemorrhage
103. During labor, to relieve supine hypotension caused by uterine atony should be given
manifested by nausea and vomiting and oxytocin as prescribed.
paleness, turn the patient on her left side. 125. Laceration of the vagina, cervix, or perineum
104. If the ovum is fertilized by a spermatozoon produces bright red bleeding that often comes
carrying a Y chromosome, a male zygote is in spurts. The bleeding is continuous, even
formed. when the fundus is firm.
126. Hot compresses can help to relieve breast 144. Tolerance is the need for increasing amounts
tenderness after breast-feeding. of a substance to achieve an effect that formerly
127. The fundus of a postpartum patient is was achieved with lesser amounts.
massaged to stimulate contraction of the uterus 145. Suicide is the third leading cause of death
and prevent hemorrhage among white teenagers.
128. A mother who has a positive human 146. Most teenagers who kill themselves made a
immunodeficiency virus test result shouldn’t previous suicide attempt and left telltale signs of
breast-feed her infant. their plans.
129. Dinoprostone (Cervidil) is used to ripen the 147. In Erikson’s stage of generativity versus
cervix. despair, generativity (investment of the self in
130. Breast-feeding of a premature neonate born the interest of the larger community) is
at 32 weeks’ gestation can be accomplished if expressed through procreation, work,
the mother expresses milk and feeds the community service, and creative endeavors.
neonate by gavage. 148. Alcoholics Anonymous recommends a 12-
131. If a pregnant patient’s rubella titer is less step program to achieve sobriety.
than 1:8, she should be immunized after 149. Signs and symptoms of anorexia nervosa
delivery. include amenorrhea, excessive weight loss,
132. The administration of oxytocin (Pitocin) is lanugo (fine body hair), abdominal distention,
stopped if the contractions are 90 seconds or and electrolyte disturbances.
longer. 150. A serum lithium level that exceeds 2.0
133. For an extramural delivery (one that takes mEq/L is considered toxic.
place outside of a normal delivery center), the 151. Public Law 94-247 (Child Abuse and Neglect
priorities for care of the neonate include Act of 1973) requires reporting of suspected
maintaining a patent airway, supporting efforts cases of child abuse to child protection services.
to breathe, monitoring vital signs, and 152. The nurse should suspect sexual abuse in a
maintaining adequate body temperature. young child who has blood in the feces or urine,
134. Subinvolution may occur if the bladder is penile or vaginal discharge, genital trauma that
distended after delivery. isn’t readily explained, or a sexually transmitted
135. A patient who has a chosen method and a disease.
plan to commit suicide in the next 48 to 72 153. An alcoholic uses alcohol to cope with the
hours is at high risk for suicide. stresses of life.
136. The therapeutic serum level for lithium is 0.5 154. The human personality operates on three
to 1.5 mEq/L. levels: conscious, preconscious, and
137. Phobic disorders are treated with unconscious.
desensitization therapy, which gradually exposes 155. Asking a patient an open-ended question is
a patient to an anxiety-producing stimulus. one of the best ways to elicit or clarify
138. Dysfunctional grieving is absent or prolonged information.
grief. 156. The diagnosis of autism is often made when
139. During phase I of the nurse-patient a child is between ages 2 and 3.
relationship (beginning, or orientation, phase), 157. Defense mechanisms protect the personality
the nurse obtains an initial history and the nurse by reducing stress and anxiety.
and the patient agree to a contract. 158. Suppression is voluntary exclusion of stress-
140. During phase II of the nurse-patient producing thoughts from the consciousness.
relationship (middle, or working, phase), the 159. In psychodrama, life situations are
patient discusses his problems, behavioral approximated in a structured environment,
changes occur, and self-defeating behavior is allowing the participant to recreate and enact
resolved or reduced. scenes to gain insight and to practice new skills.
141. During phase III of the nurse-patient 160. Psychodrama is a therapeutic technique
relationship (termination, or resolution, phase), that’s used with groups to help participants gain
the nurse terminates the therapeutic new perception and self-awareness by acting
relationship and gives the patient positive out their own or assigned problems.
feedback on his accomplishments. 161. A patient who is taking disulfiram (Antabuse)
142. According to Freud, a person between ages must avoid ingesting products that contain
12 and 20 is in the genital stage, during which alcohol, such as cough syrup, fruitcake, and
he learns independence, has an increased sauces and soups made with cooking wine.
interest in members of the opposite sex, and 162. A patient who is admitted to a psychiatric
establishes an identity. hospital involuntarily loses the right to sign out
143. According to Erikson, the identity-versus-role against medical advice.
confusion stage occurs between ages 12 and 163. “People who live in glass houses shouldn’t
20. throw stones” and “A rolling stone gathers no
 moss” are examples of proverbs used during a 181. The decision to use restraints should be
psychiatric interview to determine a patient’s based on the patient’s safety needs.
ability to think abstractly. (Schizophrenic 182. Diphenhydramine (Benadryl) relieves the
patients think in concrete terms and might extrapyramidal adverse effects of psychotropic
interpret the glass house proverb as “If you drugs.
throw a stone in a glass house, the house will 183. In a patient who is stabilized on lithium
break.”) (Eskalith) therapy, blood lithium levels should be
164. Signs of lithium toxicity include diarrhea, checked 8 to 12 hours after the first dose, then
tremors, nausea, muscle weakness, ataxia, and two or three times weekly during the first
confusion. month. Levels should be checked weekly to
165. A labile affect is characterized by rapid shifts monthly during maintenance therapy.
of emotions and mood. 184. The primary purpose of psychotropic drugs is
166. Amnesia is loss of memory from an organic to decrease the patient’s symptoms, which
or inorganic cause. improves function and increases compliance
167. A person who has borderline personality with therapy.
disorder is demanding and judgmental in 185. Manipulation is a maladaptive method of
interpersonal relationships and will attempt to meeting one’s needs because it disregards the
split staff by pointing to discrepancies in the needs and feelings of others.
treatment plan. 186. If a patient has symptoms of lithium toxicity,
168. Disulfiram (Antabuse) shouldn’t be taken the nurse should withhold one dose and call the
concurrently with metronidazole (Flagyl) physician.
because they may interact and cause a 187. A patient who is taking lithium (Eskalith) for
psychotic reaction. bipolar affective disorder must maintain a
169. In rare cases, electroconvulsive therapy balanced diet with adequate salt intake.
causes arrhythmias and death. 188. A patient who constantly seeks approval or
170. A patient who is scheduled for assistance from staff members and other
electroconvulsive therapy should receive nothing patients is demonstrating dependent behavior.
by mouth after midnight to prevent aspiration 189. Alcoholics Anonymous advocates total
while under anesthesia. abstinence from alcohol.
171. Electroconvulsive therapy is normally used 190. Methylphenidate (Ritalin) is the drug of
for patients who have severe depression that choice for treating attention deficit hyperactivity
doesn’t respond to drug therapy. disorder in children.
172. For electroconvulsive therapy to be effective, 191. Setting limits is the most effective way to
the patient usually receives 6 to 12 treatments control manipulative behavior.
at a rate of 2 to 3 per week. 192. Violent outbursts are common in a patient
173. During the manic phase of bipolar affective who has borderline personality disorder.
disorder, nursing care is directed at slowing the 193. When working with a depressed patient, the
patient down because the patient may die as a nurse should explore meaningful losses.
result of self-induced exhaustion or injury. 194. An illusion is a misinterpretation of an actual
174. For a patient with Alzheimer’s disease, the environmental stimulus.
nursing care plan should focus on safety 195. Anxiety is nonspecific; fear is specific.
measures. 196. Extrapyramidal adverse effects are common
175. After sexual assault, the patient’s needs are in patients who take antipsychotic drugs.
the primary concern, followed by medicolegal 197. The nurse should encourage an angry
considerations. patient to follow a physical exercise program as
176. Patients who are in a maintenance program one of the ways to ventilate feelings.
for narcotic abstinence syndrome receive 10 to 198. Depression is clinically significant if it’s
40 mg of methadone (Dolophine) in a single characterized by exaggerated feelings of
daily dose and are monitored to ensure that the sadness, melancholy, dejection, worthlessness,
drug is ingested. and hopelessness that are inappropriate or out
177. Stress management is a short-range goal of of proportion to reality.
psychotherapy. 199. Free-floating anxiety is anxiousness with
178. The mood most often experienced by a generalized apprehension and pessimism for
patient with organic brain syndrome is unknown reasons.
irritability. 200. In a patient who is experiencing intense
179. Creative intuition is controlled by the right anxiety, the fight-or-flight reaction (alarm
side of the brain. reflex) may take over.
180. Methohexital (Brevital) is the general 201. Confabulation is the use of imaginary
anesthetic that’s administered to patients who experiences or made-up information to fill
are scheduled for electroconvulsive therapy. missing gaps of memory.
202. When starting a therapeutic relationship with 217. Hypochondriasis is morbid anxiety about
a patient, the nurse should explain that the one’s health associated with various symptoms
purpose of the therapy is to produce a positive that aren’t caused by organic disease.
change. 218. The Minnesota Multiphasic Personality
203. A basic assumption of psychoanalytic theory Inventory consists of 550 statements for the
is that all behavior has meaning. subject to interpret. It assesses personality and
204. Catharsis is the expression of deep feelings detects disorders, such as depression and
and emotions. schizophrenia, in adolescents and adults.
205. According to the pleasure principle, the 219. Organic brain syndrome is the most common
psyche seeks pleasure and avoids unpleasant form of mental illness in elderly patients.
experiences, regardless of the consequences. 220. A person who has an IQ of less than 20 is
206. A patient who has a conversion disorder profoundly retarded and is considered a total-
resolves a psychological conflict through the loss care patient.
of a specific physical function (for example, 221. Reframing is a therapeutic technique that’s
paralysis, blindness, or inability to swallow). used to help depressed patients to view a
This loss of function is involuntary, but situation in alternative ways.
diagnostic tests show no organic cause. 222. Fluoxetine (Prozac), sertraline (Zoloft), and
207. Chlordiazepoxide (Librium) is the drug of paroxetine (Paxil) are serotonin reuptake
choice for treating alcohol withdrawal inhibitors used to treat depression.
symptoms. 223. The early stage of Alzheimer’s disease lasts 2
208. For a patient who is at risk for alcohol to 4 years. Patients have inappropriate affect,
withdrawal, the nurse should assess the pulse transient paranoia, disorientation to time,
rate and blood pressure every 2 hours for the memory loss, careless dressing, and impaired
first 12 hours, every 4 hours for the next 24 judgment.
hours, and every 6 hours thereafter (unless the 224. The middle stage of Alzheimer’s disease lasts
patient’s condition becomes unstable). 4 to 7 years and is marked by profound
209. Alcohol detoxification is most successful personality changes, loss of independence,
when carried out in a structured environment by disorientation, confusion, inability to recognize
a supportive, nonjudgmental staff. family members, and nocturnal restlessness.
210. The nurse should follow these guidelines 225. The last stage of Alzheimer’s disease occurs
when caring for a patient who is experiencing during the final year of life and is characterized
alcohol withdrawal: Maintain a calm by a blank facial expression, seizures, loss of
environment, keep intrusions to a minimum, appetite, emaciation, irritability, and total
speak slowly and calmly, adjust lighting to dependence.
prevent shadows and glare, call the patient by 226. Threatening a patient with an injection for
name, and have a friend or family member stay failing to take an oral drug is an example of
with the patient, if possible. assault.
211. The therapeutic regimen for an alcoholic 227. Reexamination of life goals is a major
patient includes folic acid, thiamine, and developmental task during middle adulthood.
multivitamin supplements as well as adequate 228. Acute alcohol withdrawal causes anorexia,
food and fluids. insomnia, headache, and restlessness and
212. A patient who is addicted to opiates (drugs escalates to a syndrome that’s characterized by
derived from poppy seeds, such as heroin and agitation, disorientation, vivid hallucinations,
morphine) typically experiences withdrawal and tremors of the hands, feet, legs, and
symptoms within 12 hours after the last dose. tongue.
The most severe symptoms occur within 48 229. In a hospitalized alcoholic, alcohol
hours and decrease over the next 2 weeks. withdrawal delirium most commonly occurs 3 to
213. Reactive depression is a response to a 4 days after admission.
specific life event. 230. Confrontation is a communication technique
214. Projection is the unconscious assigning of a in which the nurse points out discrepancies
thought, feeling, or action to someone or between the patient’s words and his nonverbal
something else. behaviors.
215. Sublimation is the channeling of 231. For a patient with substance-induced
unacceptable impulses into socially acceptable delirium, the time of drug ingestion can help to
behavior. determine whether the drug can be evacuated
216. Repression is an unconscious defense from the body.
mechanism whereby unacceptable or painful 232. Treatment for alcohol withdrawal may
thoughts, impulses, memories, or feelings are include administration of I.V. glucose for
pushed from the consciousness or forgotten. hypoglycemia, I.V. fluid containing thiamine and
 other B vitamins, and antianxiety, antidiarrheal, 250. In sensory deprivation, overall sensory input
anticonvulsant, and antiemetic drugs. is decreased.
233. The alcoholic patient receives thiamine to 251. A sign of sensory deprivation is a decrease in
help prevent peripheral neuropathy and stimulation from the environment or from within
Korsakoff’s syndrome. oneself, such as daydreaming, inactivity,
234. Alcohol withdrawal may precipitate seizure sleeping excessively, and reminiscing.
activity because alcohol lowers the seizure 252. The three stages of general adaptation
threshold in some people. syndrome are alarm, resistance, and
235. Paraphrasing is an active listening technique exhaustion.
in which the nurse restates what the patient has 253. A maladaptive response to stress is drinking
just said. alcohol or smoking excessively.
236. A patient with Korsakoff’s syndrome may use 254. Hyperalertness and the startle reflex are
confabulation (made up information) to cover characteristics of posttraumatic stress disorder.
memory lapses or periods of amnesia. 255. A treatment for a phobia is desensitization, a
237. People with obsessive-compulsive disorder process in which the patient is slowly exposed
realize that their behavior is unreasonable, but to the feared stimuli.
are powerless to control it. 256. Symptoms of major depressive disorder
238. When witnessing psychiatric patients who include depressed mood, inability to experience
are engaged in a threatening confrontation, the pleasure, sleep disturbance, appetite changes,
nurse should first separate the two individuals. decreased libido, and feelings of worthlessness.
239. Patients with anorexia nervosa or bulimia 257. Clinical signs of lithium toxicity are nausea,
must be observed during meals and for some vomiting, and lethargy.
time afterward to ensure that they don’t purge 258. Asking too many “why” questions yields
what they have eaten. scant information and may overwhelm a
240. Transsexuals believe that they were born the psychiatric patient and lead to stress and
wrong gender and may seek hormonal or withdrawal.
surgical treatment to change their gender. 259. Remote memory may be impaired in the late
241. Fugue is a dissociative state in which a stages of dementia.
person leaves his familiar surroundings, 260. According to the DSM-IV, bipolar II disorder
assumes a new identity, and has amnesia about is characterized by at least one manic episode
his previous identity. (It’s also described as that’s accompanied by hypomania.
“flight from himself.”) 261. The nurse can use silence and active
242. In a psychiatric setting, the patient should listening to promote interactions with a
be able to predict the nurse’s behavior and depressed patient.
expect consistent positive attitudes and 262. A psychiatric patient with a substance abuse
approaches. problem and a major psychiatric disorder has a
243. When establishing a schedule for a one-to- dual diagnosis.
one interaction with a patient, the nurse should 263. When a patient is readmitted to a mental
state how long the conversation will last and health unit, the nurse should assess compliance
then adhere to the time limit. with medication orders.
244. Thought broadcasting is a type of delusion in 264. Alcohol potentiates the effects of tricyclic
which the person believes that his thoughts are antidepressants.
being broadcast for the world to hear. 265. Flight of ideas is movement from one topic
245. Lithium should be taken with food. A patient to another without any discernible connection.
who is taking lithium shouldn’t restrict his 266. Conduct disorder is manifested by extreme
sodium intake. behavior, such as hurting people and animals.
246. A patient who is taking lithium should stop 267. During the “tension-building” phase of an
taking the drug and call his physician if he abusive relationship, the abused individual feels
experiences vomiting, drowsiness, or muscle helpless.
weakness. 268. In the emergency treatment of an alcohol-
247. The patient who is taking a monoamine intoxicated patient, determining the blood-
oxidase inhibitor for depression can include alcohol level is paramount in determining the
cottage cheese, cream cheese, yogurt, and sour amount of medication that the patient needs.
cream in his diet. 269. Side effects of the antidepressant fluoxetine
248. Sensory overload is a state in which sensory (Prozac) include diarrhea, decreased libido,
stimulation exceeds the individual’s capacity to weight loss, and dry mouth.
tolerate or process it. 270. Before electroconvulsive therapy, the patient
249. Symptoms of sensory overload include a is given the skeletal muscle relaxant
feeling of distress and hyperarousal with succinylcholine (Anectine) by I.V.
impaired thinking and concentration. administration.
271. When a psychotic patient is admitted to an 293. Transvestism is a desire to wear clothes
inpatient facility, the primary concern is safety, usually worn by members of the opposite sex.
followed by the establishment of trust. 294. Tardive dyskinesia causes excessive blinking
272. An effective way to decrease the risk of and unusual movement of the tongue, and
suicide is to make a suicide contract with the involuntary sucking and chewing.
patient for a specified period of time. 295. Trihexyphenidyl (Artane) and benztropine
273. A depressed patient should be given (Cogentin) are administered to counteract
sufficient portions of his favorite foods, but extrapyramidal adverse effects.
shouldn’t be overwhelmed with too much food. 296. To prevent hypertensive crisis, a patient who
274. The nurse should assess the depressed is taking a monoamine oxidase inhibitor should
patient for suicidal ideation. avoid consuming aged cheese, caffeine, beer,
275. Delusional thought patterns commonly occur yeast, chocolate, liver, processed foods, and
during the manic phase of bipolar disorder. monosodium glutamate.
276. Apathy is typically observed in patients who 297. Extrapyramidal symptoms include
have schizophrenia. parkinsonism, dystonia, akathisia (“ants in the
277. Manipulative behavior is characteristic of a pants”), and tardive dyskinesia.
patient who has passive– aggressive personality 298. One theory that supports the use of
disorder. electroconvulsive therapy suggests that it
278. When a patient who has schizophrenia “resets” the brain circuits to allow normal
begins to hallucinate, the nurse should redirect function.
the patient to activities that are focused on the 299. A patient who has obsessive-compulsive
here and now. disorder usually recognizes the senselessness of
279. When a patient who is receiving an his behavior but is powerless to stop it (ego-
antipsychotic drug exhibits muscle rigidity and dystonia).
tremors, the nurse should administer an 300. In helping a patient who has been abused,
antiparkinsonian drug (for example, Cogentin or physical safety is the nurse’s first priority.
Artane) as ordered. 301. Pemoline (Cylert) is used to treat attention
280. A patient who is receiving lithium (Eskalith) deficit hyperactivity disorder (ADHD).
therapy should report diarrhea, vomiting, 302. Clozapine (Clozaril) is contraindicated in
drowsiness, muscular weakness, or lack of pregnant women and in patients who have
coordination to the physician immediately. severe granulocytopenia or severe central
281. The therapeutic serum level of lithium nervous system depression.
(Eskalith) for maintenance is 0.6 to 1.2 mEq/L. 303. Repression, an unconscious process, is the
282. Obsessive-compulsive disorder is an anxiety- inability to recall painful or unpleasant thoughts
related disorder. or feelings.
283. Al-Anon is a self-help group for families of 304. Projection is shifting of unwanted
alcoholics. characteristics or shortcomings to others
284. Desensitization is a treatment for phobia, or (scapegoat).
irrational fear. 305. Hypnosis is used to treat psychogenic
285. After electroconvulsive therapy, the patient amnesia.
is placed in the lateral position, with the head 306. Disulfiram (Antabuse) is administered orally
turned to one side. as an aversion therapy to treat alcoholism.
286. A delusion is a fixed false belief. 307. Ingestion of alcohol by a patient who is
287. Giving away personal possessions is a sign of taking disulfiram (Antabuse) can cause severe
suicidal ideation. Other signs include writing a reactions, including nausea and vomiting, and
suicide note or talking about suicide. may endanger the patient’s life.
288. Agoraphobia is fear of open spaces. 308. Improved concentration is a sign that lithium
289. A person who has paranoid personality is taking effect.
disorder projects hostilities onto others. 309. Behavior modification, including time-outs,
290. To assess a patient’s judgment, the nurse token economy, or a reward system, is a
should ask the patient what he would do if he treatment for attention deficit hyperactivity
found a stamped, addressed envelope. An disorder.
appropriate response is that he would mail the 310. For a patient who has anorexia nervosa, the
envelope. nurse should provide support at mealtime and
291. After electroconvulsive therapy, the patient record the amount the patient eats.
should be monitored for post-shock amnesia. 311. A significant toxic risk associated with
292. A mother who continues to perform clozapine (Clozaril) administration is blood
cardiopulmonary resuscitation after a physician dyscrasia.
pronounces a child dead is showing denial. 312. Adverse effects of haloperidol (Haldol)
administration include drowsiness; insomnia;
 weakness; headache; and extrapyramidal 13. In an emergency, consent for treatment can be
symptoms, such as akathisia, tardive dyskinesia, obtained by fax, telephone, or other telegraphic
and dystonia. means.
313. Hypervigilance and déjà vu are signs of
posttraumatic stress disorder (PTSD). 14. Decibel is the unit of measurement of sound.
314. A child who shows dissociation has probably
been abused. 15. Informed consent is required for any invasive
315. Confabulation is the use of fantasy to fill in procedure.
gaps of memory.
16. A patient who can’t write his name to give
 FUNDAMENTAL I
consent for treatment must make an X in the
presence of two witnesses, such as a nurse, priest, or
Go!
physician.

1. A blood pressure cuff that’s too narrow can cause a

17. The Z-track I.M. injection technique seals the
falsely elevated blood pressure reading.
drug deep into the muscle, thereby minimizing skin
irritation and staining. It requires a needle that’s 1″
2. When preparing a single injection for a patient who
(2.5 cm) or longer.
takes regular and neutral protein Hagedorn insulin,
the nurse should draw the regular insulin into the
18. In the event of fire, the acronym most often used
syringe first so that it does not contaminate the
is RACE. (R) Remove the patient. (A) Activate the
regular insulin.
alarm. (C) Attempt to contain the fire by closing the
door. (E) Extinguish the fire if it can be done safely.
3. Rhonchi are the rumbling sounds heard on lung
auscultation. They are more pronounced during
19. A registered nurse should assign a licensed
expiration than during inspiration.
vocational nurse or licensed practical nurse to
perform bedside care, such as suctioning and drug
4. Gavage is forced feeding, usually through a gastric
administration.
tube (a tube passed into the stomach through the
mouth).
20. If a patient can’t void, the first nursing action
should be bladder palpation to assess for bladder
5. According to Maslow’s hierarchy of needs,
distention.
physiologic needs (air, water, food, shelter, sex,
activity, and comfort) have the highest priority.
21. The patient who uses a cane should carry it on
the unaffected side and advance it at the same time
6. The safest and surest way to verify a patient’s
as the affected extremity.
identity is to check the identification band on his
wrist.
22. To fit a supine patient for crutches, the nurse
should measure from the axilla to the sole and add 2″
7. In the therapeutic environment, the patient’s safety
(5 cm) to that measurement.
is the primary concern.

23. Assessment begins with the nurse’s first

8. Fluid oscillation in the tubing of a chest drainage
encounter with the patient and continues throughout
system indicates that the system is working properly.
the patient’s stay. The nurse obtains assessment data
through the health history, physical examination, and
9. The nurse should place a patient who has a
review of diagnostic studies.
Sengstaken-Blakemore tube in semi-Fowler position.

24. The appropriate needle size for insulin injection is

10. The nurse can elicit Trousseau’s sign by occluding
25G and 5/8″ long.
the brachial or radial artery. Hand and finger spasms
that occur during occlusion indicate Trousseau’s sign
25. Residual urine is urine that remains in the bladder
and suggest hypocalcemia.
after voiding. The amount of residual urine is
normally 50 to 100 ml.
11. For blood transfusion in an adult, the appropriate
needle size is 16 to 20G.
26. The five stages of the nursing process are
assessment, nursing diagnosis, planning,
12. Intractable pain is pain that incapacitates a
implementation, and evaluation.
patient and can’t be relieved by drugs.
27. Assessment is the stage of the nursing process in 41. A positive Homan’s sign may indicate
which the nurse continuously collects data to identify thrombophlebitis.
a patient’s actual and potential health needs.
42. Electrolytes in a solution are measured in
28. Nursing diagnosis is the stage of the nursing milliequivalents per liter (mEq/L). A milliequivalent is
process in which the nurse makes a clinical judgment the number of milligrams per 100 milliliters of a
about individual, family, or community responses to solution.
actual or potential health problems or life processes.
43. Metabolism occurs in two phases: anabolism (the
29. Planning is the stage of the nursing process in constructive phase) and catabolism (the destructive
which the nurse assigns priorities to nursing phase).
diagnoses, defines short-term and long-term goals
and expected outcomes, and establishes the nursing 44. The basal metabolic rate is the amount of energy
care plan. needed to maintain essential body functions. It’s
measured when the patient is awake and resting,
30. Implementation is the stage of the nursing hasn’t eaten for 14 to 18 hours, and is in a
process in which the nurse puts the nursing care plan comfortable, warm environment.
into action, delegates specific nursing interventions to
members of the nursing team, and charts patient 45. The basal metabolic rate is expressed in calories
responses to nursing interventions. consumed per hour per kilogram of body weight.

31. Evaluation is the stage of the nursing process in 46. Dietary fiber (roughage), which is derived from
which the nurse compares objective and subjective cellulose, supplies bulk, maintains intestinal motility,
data with the outcome criteria and, if needed, and helps to establish regular bowel habits.
modifies the nursing care plan.
47. Alcohol is metabolized primarily in the liver.
32. Before administering any “as needed” pain Smaller amounts are metabolized by the kidneys and
medication, the nurse should ask the patient to lungs.
indicate the location of the pain.
48. Petechiae are tiny, round, purplish red spots that
33. Jehovah’s Witnesses believe that they shouldn’t appear on the skin and mucous membranes as a
receive blood components donated by other people. result of intradermal or submucosal hemorrhage.

34. To test visual acuity, the nurse should ask the 49. Purpura is a purple discoloration of the skin that’s
patient to cover each eye separately and to read the caused by blood extravasation.
eye chart with glasses and without, as appropriate.
50. According to the standard precautions
35. When providing oral care for an unconscious recommended by the Centers for Disease Control and
patient, to minimize the risk of aspiration, the nurse Prevention, the nurse shouldn’t recap needles after
should position the patient on the side. use. Most needle sticks result from missed needle
recapping.
36. During assessment of distance vision, the patient
should stand 20′ (6.1 m) from the chart. 51. The nurse administers a drug by I.V. push by
using a needle and syringe to deliver the dose directly
37. For a geriatric patient or one who is extremely ill, into a vein, I.V. tubing, or a catheter.
the ideal room temperature is 66° to 76° F (18.8° to
24.4° C). 52. When changing the ties on a tracheostomy tube,
the nurse should leave the old ties in place until the
38. Normal room humidity is 30% to 60%. new ones are applied.

39. Hand washing is the single best method of 53. A nurse should have assistance when changing
limiting the spread of microorganisms. Once gloves the ties on a tracheostomy tube.
are removed after routine contact with a patient,
hands should be washed for 10 to 15 seconds. 54. A filter is always used for blood transfusions.

40. To perform catheterization, the nurse should 55. A four-point (quad) cane is indicated when a
place a woman in the dorsal recumbent position. patient needs more stability than a regular cane can
provide.
56. A good way to begin a patient interview is to ask, antimicrobial soap, has had mouth care (without
“What made you seek medical help?” swallowing the water), has removed common jewelry,
and has received preoperative medication as
57. When caring for any patient, the nurse should prescribed; and that vital signs have been taken and
follow standard precautions for handling blood and recorded. Artificial limbs and other prostheses are
body fluids. usually removed.
58. Potassium (K+) is the most abundant cation in
intracellular fluid. 70. Comfort measures, such as positioning the
patient, rubbing the patient’s back, and providing a
59. In the four-point, or alternating, gait, the patient restful environment, may decrease the patient’s need
first moves the right crutch followed by the left foot for analgesics or may enhance their effectiveness.
and then the left crutch followed by the right foot.
71. A drug has three names: generic name, which is
60. In the three-point gait, the patient moves two used in official publications; trade, or brand, name
crutches and the affected leg simultaneously and then (such as Tylenol), which is selected by the drug
moves the unaffected leg. company; and chemical name, which describes the
drug’s chemical composition.
61. In the two-point gait, the patient moves the right
leg and the left crutch simultaneously and then moves 72. To avoid staining the teeth, the patient should
the left leg and the right crutch simultaneously. take a liquid iron preparation through a straw.

62. The vitamin B complex, the water-soluble 73. The nurse should use the Z-track method to
vitamins that are essential for metabolism, include administer an I.M. injection of iron dextran (Imferon).
thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine
(B6), and cyanocobalamin (B12). 74. An organism may enter the body through the
nose, mouth, rectum, urinary or reproductive tract, or
63. When being weighed, an adult patient should be skin.
lightly dressed and shoeless.
75. In descending order, the levels of consciousness
64. Before taking an adult’s temperature orally, the are alertness, lethargy, stupor, light coma, and deep
nurse should ensure that the patient hasn’t smoked or coma.
consumed hot or cold substances in the previous 15
minutes. 76. To turn a patient by logrolling, the nurse folds the
patient’s arms across the chest; extends the patient’s
65. The nurse shouldn’t take an adult’s temperature legs and inserts a pillow between them, if needed;
rectally if the patient has a cardiac disorder, anal places a draw sheet under the patient; and turns the
lesions, or bleeding hemorrhoids or has recently patient by slowly and gently pulling on the draw
undergone rectal surgery. sheet.

66. In a patient who has a cardiac disorder, 77. The diaphragm of the stethoscope is used to hear
measuring temperature rectally may stimulate a vagal high-pitched sounds, such as breath sounds.
response and lead to vasodilation and decreased
cardiac output. 78. A slight difference in blood pressure (5 to 10 mm
Hg) between the right and the left arms is normal.
67. When recording pulse amplitude and rhythm, the
nurse should use these descriptive measures: +3, 79. The nurse should place the blood pressure cuff 1″
bounding pulse (readily palpable and forceful); +2, (2.5 cm) above the antecubital fossa.
normal pulse (easily palpable); +1, thready or weak
pulse (difficult to detect); and 0, absent pulse (not 80. When instilling ophthalmic ointments, the nurse
detectable). should waste the first bead of ointment and then
apply the ointment from the inner canthus to the
68. The intraoperative period begins when a patient is outer canthus.
transferred to the operating room bed and ends when
the patient is admitted to the postanesthesia care 81. The nurse should use a leg cuff to measure blood
unit. pressure in an obese patient.

69. On the morning of surgery, the nurse should 82. If a blood pressure cuff is applied too loosely, the
ensure that the informed consent form has been reading will be falsely elevated.
signed; that the patient hasn’t taken anything by
mouth since midnight, has taken a shower with
83. Ptosis is drooping of the eyelid. 95. In documenting drainage on a surgical dressing,
the nurse should include the size, color, and
84. A tilt table is useful for a patient with a spinal consistency of the drainage (for example, “10 mm of
cord injury, orthostatic hypotension, or brain damage brown mucoid drainage noted on dressing”).
because it can move the patient gradually from a
horizontal to a vertical (upright) position. 96. To elicit Babinski’s reflex, the nurse strokes the
sole of the patient’s foot with a moderately sharp
85. To perform venipuncture with the least injury to object, such as a thumbnail.
the vessel, the nurse should turn the bevel upward
when the vessel’s lumen is larger than the needle and 97. A positive Babinski’s reflex is shown by
turn it downward when the lumen is only slightly dorsiflexion of the great toe and fanning out of the
larger than the needle. other toes.

86. To move a patient to the edge of the bed for 98. When assessing a patient for bladder distention,
transfer, the nurse should follow these steps: Move the nurse should check the contour of the lower
the patient’s head and shoulders toward the edge of abdomen for a rounded mass above the symphysis
the bed. Move the patient’s feet and legs to the edge pubis.
of the bed (crescent position). Place both arms well
under the patient’s hips, and straighten the back 99. The best way to prevent pressure ulcers is to
while moving the patient toward the edge of the bed. reposition the bedridden patient at least every 2
hours.
87. When being measured for crutches, a patient
should wear shoes. 100. Antiembolism stockings decompress the
superficial blood vessels, reducing the risk of
88. The nurse should attach a restraint to the part of thrombus formation.
the bed frame that moves with the head, not to the
mattress or side rails. 101. In adults, the most convenient veins for
venipuncture are the basilic and median cubital veins
89. The mist in a mist tent should never become so in the antecubital space.
dense that it obscures clear visualization of the
patient’s respiratory pattern. 102. Two to three hours before beginning a tube
feeding, the nurse should aspirate the patient’s
90. To administer heparin subcutaneously, the nurse stomach contents to verify that gastric emptying is
should follow these steps: Clean, but don’t rub, the adequate.
site with alcohol. Stretch the skin taut or pick up a
well-defined skin fold. Hold the shaft of the needle in 103. People with type O blood are considered
a dart position. Insert the needle into the skin at a universal donors.
right (90-degree) angle. Firmly depress the plunger,
but don’t aspirate. Leave the needle in place for 10 104. People with type AB blood are considered
seconds. Withdraw the needle gently at the angle of universal recipients.
insertion. Apply pressure to the injection site with an
alcohol pad. 105. Hertz (Hz) is the unit of measurement of sound
frequency.
91. For a sigmoidoscopy, the nurse should place the
patient in the knee-chest position or Sims’ position, 106. Hearing protection is required when the sound
depending on the physician’s preference. intensity exceeds 84 dB. Double hearing protection is
required if it exceeds 104 dB.
92. Maslow’s hierarchy of needs must be met in the
following order: physiologic (oxygen, food, water, 107. Prothrombin, a clotting factor, is produced in the
sex, rest, and comfort), safety and security, love and liver.
belonging, self-esteem and recognition, and self-
actualization. 108. If a patient is menstruating when a urine sample
is collected, the nurse should note this on the
93. When caring for a patient who has a nasogastric laboratory request.
tube, the nurse should apply a water-soluble lubricant
to the nostril to prevent soreness. 109. During lumbar puncture, the nurse must note
the initial intracranial pressure and the color of the
94. During gastric lavage, a nasogastric tube is cerebrospinal fluid.
inserted, the stomach is flushed, and ingested
substances are removed through the tube.
110. If a patient can’t cough to provide a sputum 125. A patient’s bed bath should proceed in this
sample for culture, a heated aerosol treatment can be order: face, neck, arms, hands, chest, abdomen,
used to help to obtain a sample. back, legs, perineum.

111. If eye ointment and eyedrops must be instilled in 126. To prevent injury when lifting and moving a
the same eye, the eyedrops should be instilled first. patient, the nurse should primarily use the upper leg
muscles.
112. When leaving an isolation room, the nurse
should remove her gloves before her mask because 127. Patient preparation for cholecystography
fewer pathogens are on the mask. includes ingestion of a contrast medium and a low-fat
evening meal.
113. Skeletal traction, which is applied to a bone with
wire pins or tongs, is the most effective means of 128. While an occupied bed is being changed, the
traction. patient should be covered with a bath blanket to
promote warmth and prevent exposure.
114. The total parenteral nutrition solution should be
stored in a refrigerator and removed 30 to 60 minutes 129. Anticipatory grief is mourning that occurs for an
before use. Delivery of a chilled solution can cause extended time when the patient realizes that death is
pain, hypothermia, venous spasm, and venous inevitable.
constriction. 130. The following foods can alter the color of the
feces: beets (red), cocoa (dark red or brown), licorice
115. Drugs aren’t routinely injected intramuscularly (black), spinach (green), and meat protein (dark
into edematous tissue because they may not be brown).
absorbed.
131. When preparing for a skull X-ray, the patient
116. When caring for a comatose patient, the nurse should remove all jewelry and dentures.
should explain each action to the patient in a normal
voice. 132. The fight-or-flight response is a sympathetic
nervous system response.
117. Dentures should be cleaned in a sink that’s lined
with a washcloth. 133. Bronchovesicular breath sounds in peripheral
lung fields are abnormal and suggest pneumonia.
118. A patient should void within 8 hours after
surgery. 134. Wheezing is an abnormal, high-pitched breath
sound that’s accentuated on expiration.
119. An EEG identifies normal and abnormal brain
waves. 135. Wax or a foreign body in the ear should be
flushed out gently by irrigation with warm saline
120. Samples of feces for ova and parasite tests solution.
should be delivered to the laboratory without delay
and without refrigeration. 136. If a patient complains that his hearing aid is “not
working,” the nurse should check the switch first to
121. The autonomic nervous system regulates the see if it’s turned on and then check the batteries.
cardiovascular and respiratory systems.
137. The nurse should grade hyperactive biceps and
122. When providing tracheostomy care, the nurse triceps reflexes as +4.
should insert the catheter gently into the
tracheostomy tube. When withdrawing the catheter, 138. If two eye medications are prescribed for twice-
the nurse should apply intermittent suction for no daily instillation, they should be administered 5
more than 15 seconds and use a slight twisting minutes apart.
motion.
139. In a postoperative patient, forcing fluids helps
123. A low-residue diet includes such foods as prevent constipation.
roasted chicken, rice, and pasta.
140. A nurse must provide care in accordance with
124. A rectal tube shouldn’t be inserted for longer standards of care established by the American Nurses
than 20 minutes because it can irritate the rectal Association, state regulations, and facility policy.
mucosa and cause loss of sphincter control.
141. The kilocalorie (kcal) is a unit of energy chronologically, beginning with the onset of the
measurement that represents the amount of heat problem and continuing to the present.
needed to raise the temperature of 1 kilogram of
water 1° C. 155. When assessing a patient’s health history, the
nurse should record the current illness
142. As nutrients move through the body, they chronologically, beginning with the onset of the
undergo ingestion, digestion, absorption, transport, problem and continuing to the present.
cell metabolism, and excretion.
156. A nurse shouldn’t give false assurance to a
143. The body metabolizes alcohol at a fixed rate, patient.
regardless of serum concentration.
157. After receiving preoperative medication, a
144. In an alcoholic beverage, proof reflects the patient isn’t competent to sign an informed consent
percentage of alcohol multiplied by 2. For example, a form.
100-proof beverage contains 50% alcohol.
158. When lifting a patient, a nurse uses the weight
145. A living will is a witnessed document that states of her body instead of the strength in her arms.
a patient’s desire for certain types of care and
treatment. These decisions are based on the patient’s 159. A nurse may clarify a physician’s explanation
wishes and views on quality of life. about an operation or a procedure to a patient, but
must refer questions about informed consent to the
146. The nurse should flush a peripheral heparin lock physician.
every 8 hours (if it wasn’t used during the previous 8
hours) and as needed with normal saline solution to 160. When obtaining a health history from an acutely
maintain patency. ill or agitated patient, the nurse should limit questions
to those that provide necessary information.
147. Quality assurance is a method of determining
whether nursing actions and practices meet 161. If a chest drainage system line is broken or
established standards. interrupted, the nurse should clamp the tube
immediately.
148. The five rights of medication administration are
the right patient, right drug, right dose, right route of 162. The nurse shouldn’t use her thumb to take a
administration, and right time. patient’s pulse rate because the thumb has a pulse
that may be confused with the patient’s pulse.
149. The evaluation phase of the nursing process is to
determine whether nursing interventions have 163. An inspiration and an expiration count as one
enabled the patient to meet the desired goals. respiration.

150. Outside of the hospital setting, only the 164. Eupnea is normal respiration.
sublingual and translingual forms of nitroglycerin
should be used to relieve acute anginal attacks. 165. During blood pressure measurement, the patient
should rest the arm against a surface. Using muscle
151. The implementation phase of the nursing strength to hold up the arm may raise the blood
process involves recording the patient’s response to pressure.
the nursing plan, putting the nursing plan into action,
delegating specific nursing interventions, and 166. Major, unalterable risk factors for coronary
coordinating the patient’s activities. artery disease include heredity, sex, race, and age.

152. The Patient’s Bill of Rights offers patients 167. Inspection is the most frequently used
guidance and protection by stating the responsibilities assessment technique.
of the hospital and its staff toward patients and their
families during hospitalization. 168. Family members of an elderly person in a long-
term care facility should transfer some personal items
153. To minimize omission and distortion of facts, the (such as photographs, a favorite chair, and
nurse should record information as soon as it’s knickknacks) to the person’s room to provide a
gathered. comfortable atmosphere.

154. When assessing a patient’s health history, the 169. Pulsus alternans is a regular pulse rhythm with
nurse should record the current illness alternating weak and strong beats. It occurs in
ventricular enlargement because the stroke volume (loud, as heard over a normal lung), dullness
varies with each heartbeat. (medium intensity, as heard over the liver or other
solid organ), and flatness (soft, as heard over the
170. The upper respiratory tract warms and thigh).
humidifies inspired air and plays a role in taste, smell,
and mastication. 184. The optic disk is yellowish pink and circular, with
a distinct border.
171. Signs of accessory muscle use include shoulder
elevation, intercostal muscle retraction, and scalene 185. A primary disability is caused by a pathologic
and sternocleidomastoid muscle use during process. A secondary disability is caused by inactivity.
respiration.
186. Nurses are commonly held liable for failing to
172. When patients use axillary crutches, their palms keep an accurate count of sponges and other devices
should bear the brunt of the weight. during surgery.

173. Activities of daily living include eating, bathing, 187. The best dietary sources of vitamin B6 are liver,
dressing, grooming, toileting, and interacting socially. kidney, pork, soybeans, corn, and whole-grain
cereals.
174. Normal gait has two phases: the stance phase,
in which the patient’s foot rests on the ground, and 188. Iron-rich foods, such as organ meats, nuts,
the swing phase, in which the patient’s foot moves legumes, dried fruit, green leafy vegetables, eggs,
forward. and whole grains, commonly have a low water
content.
175. The phases of mitosis are prophase, metaphase,
anaphase, and telophase. 189. Collaboration is joint communication and
decision making between nurses and physicians. It’s
176. The nurse should follow standard precautions in designed to meet patients’ needs by integrating the
the routine care of all patients. care regimens of both professions into one
comprehensive approach.
177. The nurse should use the bell of the stethoscope
to listen for venous hums and cardiac murmurs. 190. Bradycardia is a heart rate of fewer than 60
beats/minute.
178. The nurse can assess a patient’s general
knowledge by asking questions such as “Who is the 191. A nursing diagnosis is a statement of a patient’s
president of the United States?” actual or potential health problem that can be
resolved, diminished, or otherwise changed by
179. Cold packs are applied for the first 20 to 48 nursing interventions.
hours after an injury; then heat is applied. During
cold application, the pack is applied for 20 minutes 192. During the assessment phase of the nursing
and then removed for 10 to 15 minutes to prevent process, the nurse collects and analyzes three types
reflex dilation (rebound phenomenon) and frostbite of data: health history, physical examination, and
injury. laboratory and diagnostic test data.
180. The pons is located above the medulla and
consists of white matter (sensory and motor tracts) 193. The patient’s health history consists primarily of
and gray matter (reflex centers). subjective data, information that’s supplied by the
patient.
181. The autonomic nervous system controls the
smooth muscles. 194. The physical examination includes objective data
obtained by inspection, palpation, percussion, and
182. A correctly written patient goal expresses the auscultation.
desired patient behavior, criteria for measurement,
time frame for achievement, and conditions under 195. When documenting patient care, the nurse
which the behavior will occur. It’s developed in should write legibly, use only standard abbreviations,
collaboration with the patient. and sign each entry. The nurse should never destroy
or attempt to obliterate documentation or leave
183. Percussion causes five basic notes: tympany vacant lines.
(loud intensity, as heard over a gastric air bubble or
puffed out cheek), hyperresonance (very loud, as
heard over an emphysematous lung), resonance
196. Factors that affect body temperature include 209. O.U. means each eye. O.D. is the right eye, and
time of day, age, physical activity, phase of menstrual O.S. is the left eye.
cycle, and pregnancy.
210. To remove a patient’s artificial eye, the nurse
197. The most accessible and commonly used artery depresses the lower lid.
for measuring a patient’s pulse rate is the radial
artery. To take the pulse rate, the artery is 211. The nurse should use a warm saline solution to
compressed against the radius. clean an artificial eye.

198. In a resting adult, the normal pulse rate is 60 to 212. A thready pulse is very fine and scarcely
100 beats/minute. The rate is slightly faster in women perceptible.
than in men and much faster in children than in
adults. 213. Axillary temperature is usually 1° F lower than
oral temperature.
199. Laboratory test results are an objective form of
assessment data. 214. After suctioning a tracheostomy tube, the nurse
must document the color, amount, consistency, and
200. The measurement systems most commonly used odor of secretions.
in clinical practice are the metric system,
apothecaries’ system, and household system. 215. On a drug prescription, the abbreviation p.c.
means that the drug should be administered after
201. Before signing an informed consent form, the meals.
patient should know whether other treatment options
are available and should understand what will occur 216. After bladder irrigation, the nurse should
during the preoperative, intraoperative, and document the amount, color, and clarity of the urine
postoperative phases; the risks involved; and the and the presence of clots or sediment.
possible complications. The patient should also have a
general idea of the time required from surgery to 217. After bladder irrigation, the nurse should
recovery. In addition, he should have an opportunity document the amount, color, and clarity of the urine
to ask questions. and the presence of clots or sediment.

202. A patient must sign a separate informed consent 218. Laws regarding patient self-determination vary
form for each procedure. from state to state. Therefore, the nurse must be
familiar with the laws of the state in which she works.
203. During percussion, the nurse uses quick, sharp
tapping of the fingers or hands against body surfaces 219. Gauge is the inside diameter of a needle: the
to produce sounds. This procedure is done to smaller the gauge, the larger the diameter.
determine the size, shape, position, and density of
underlying organs and tissues; elicit tenderness; or 220. An adult normally has 32 permanent teeth.
assess reflexes.

FUNDAMENTALS II
204. Ballottement is a form of light palpation involving
gentle, repetitive bouncing of tissues against the hand Go!
and feeling their rebound.

1. After turning a patient, the nurse

205. A foot cradle keeps bed linen off the patient’s should document the position used, the time that the
feet to prevent skin irritation and breakdown, patient was turned, and the findings of skin
especially in a patient who has peripheral vascular assessment.
disease or neuropathy.

2. PERRLA is an abbreviation for normal pupil

206. Gastric lavage is flushing of the stomach and assessment findings: pupils equal, round, and reactive
removal of ingested substances through a nasogastric to light withaccommodation.
tube. It’s used to treat poisoning or drug overdose.

3. When percussing a patient’s chest for postural

207. During the evaluation step of the nursing drainage, the nurse’s hands should be cupped.
process, the nurse assesses the patient’s response to
therapy. 4. When measuring a patient’s pulse, the nurse
should assess its rate, rhythm, quality, and strength.
208. Bruits commonly indicate life- or limb-
threatening vascular disease.
5. Before transferring a patient from a bed to a 20. As a general rule, nurses can’t refuse a patient
wheelchair, the nurse should push the wheelchair’s care assignment; however, in most states, they may
footrests to the sides and lock its wheels. refuse to participate in abortions.

6. When assessing respirations, the nurse 21. A nurse can be found negligent if a patient is
should document their rate, rhythm, depth, and injured because the nurse failed to perform a duty
quality. that a reasonable and prudent person would perform
or because the nurse performed an act that a
7. For a subcutaneous injection, the nurse should use reasonable and prudent person wouldn’t perform.
a 5/8″ 25G needle.
22. States have enacted Good Samaritan laws to
8. The notation “AA & O × 3” indicates that the encourage professionals to provide medical assistance
patient is awake, alert, and oriented to person (knows at the scene of an accident without fear of a lawsuit
who he is), place (knows where he is), and time arising from the assistance. These laws don’t apply to
(knows the date and time). care provided in ahealth care facility.

9. Fluid intake includes all fluids taken by mouth, 23. A physician should sign verbal and telephone
including foods that are liquid at room temperature, orders within the time established by facility policy,
such as gelatin, custard, and ice cream; I.V. fluids; usually 24 hours.
and fluids administered in feeding tubes. Fluid output
includes urine, vomitus, and drainage (such as from a 24. A competent adult has the right to refuse
nasogastric tube or from a wound) as well as blood lifesaving medical treatment; however, the individual
loss, diarrhea or feces, and perspiration. should be fully informed of the consequences of his
refusal.
10. After administering an intradermal injection, the
nurse shouldn’t massage the area because massage 25. Although a patient’s health record, or chart, is
can irritate the site and interfere with results. the health care facility’s physical property, its contents
belong to the patient.
11. When administering an intradermal injection, the
nurse should hold the syringe almost flat against the 26. Before a patient’s health record can be released
patient’s skin (at about a 15-degree angle), with the to a third party, the patient or the patient’s legal
bevel up. guardian must give written consent.

12. To obtain an accurate blood pressure, the nurse 27. Under the Controlled Substances Act, every dose
should inflate the manometer to 20 to 30 mm Hg of a controlled drug that’s dispensed by the pharmacy
above the disappearance of the radial pulse before must be accounted for, whether the dose was
releasing the cuff pressure. administered to a patient or discarded accidentally.

13. The nurse should count an irregular pulse for 1 28. A nurse can’t perform duties that violate a rule or
full minute. regulation established by a state licensing board, even
if they are authorized by a health care facility or
14. A patient who is vomiting while lying down should physician.
be placed in a lateral position to prevent aspiration of
vomitus. 29. To minimize interruptions during a patient
interview, the nurse should select a private room,
15. Prophylaxis is disease prevention. preferably one with a door that can be closed.

16. Body alignment is achieved when body parts are 30. In categorizing nursing diagnoses, the nurse
in proper relation to their natural position. addresses life-threatening problems first, followed by
potentially life-threatening concerns.
17. Trust is the foundation of a nurse-patient
relationship. 31. The major components of a nursing care plan are
outcome criteria (patient goals) and nursing
18. Blood pressure is the force exerted by the interventions.
circulating volume of blood on the arterial walls.
32. Standing orders, or protocols, establish guidelines
19. Malpractice is a professional’s wrongful conduct, for treating a specific disease or set of symptoms.
improper discharge of duties, or failure to meet
standards of care that causes harm to another.
33. In assessing a patient’s heart, the nurse normally 47. The most important goal to include in a care plan
finds the point of maximal impulse at the is the patient’s goal.
fifth intercostalspace, near the apex.
48. Fruits are high in fiber and low in protein, and
34. The S1 heard on auscultation is caused by closure should be omitted from a low-residue diet.
of the mitral and tricuspid valves.
49. The nurse should use an objective scale to assess
35. To maintain package sterility, the nurse should and quantify pain. Postoperative pain varies greatly
open a wrapper’s top flap away from the body, open among individuals.
each side flap by touching only the outer part of the
wrapper, and open the final flap by grasping the 50. Postmortem care includes cleaning and preparing
turned-down corner and pulling it toward the body. the deceased patient for family viewing, arranging
transportation to the morgue or funeral home, and
36. The nurse shouldn’t dry a patient’s ear canal or determining the disposition of belongings.
remove wax with a cotton-tipped applicator because it
may force cerumen against the tympanic membrane. 51. The nurse should provide honest answers to the
patient’s questions.
37. A patient’s identification bracelet should remain in
place until the patient has been discharged from 52. Milk shouldn’t be included in a clear liquid diet.
the health care facility and has left the premises.
53. When caring for an infant, a child, or a confused
38. The Controlled Substances Act designated five patient, consistency in nursing personnel is
categories, or schedules, that classify controlled drugs paramount.
according to their abuse potential.
39. Schedule I drugs, such as heroin, have a high 54. The hypothalamus secretes vasopressin and
abuse potential and have no currently accepted oxytocin, which are stored in the pituitary gland.
medical use in the United States.
55. The three membranes that enclose the brain and
40. Schedule II drugs, such as morphine, opium, and spinal cord are the dura mater, pia mater, and
meperidine (Demerol), have a high abuse potential, arachnoid.
but currently have accepted medical uses. Their use
may lead to physical or psychological dependence. 56. A nasogastric tube is used to remove fluid and
gas from the small intestine preoperatively or
41. Schedule III drugs, such as paregoric and postoperatively.
butabarbital (Butisol), have a lower abuse potential
than Schedule I or II drugs. Abuse of Schedule III 57. Psychologists, physical therapists, and
drugs may lead to moderate or low physical or chiropractors aren’t authorized to write prescriptions
psychological dependence, or both. for drugs.

42. Schedule IV drugs, such as chloral hydrate, have 58. The area around a stoma is cleaned with mild
a low abuse potential compared with Schedule III soap and water.
drugs.
59. Vegetables have a high fiber content.
43. Schedule V drugs, such as cough syrups that
contain codeine, have the lowest abuse potential of 60. The nurse should use a tuberculin syringe to
the controlled substances. administer a subcutaneous injection of less than 1 ml.

44. Activities of daily living are actions that the 61. For adults, subcutaneous injections require a 25G
patient must perform every day to provide self-care 1″ needle; for infants, children, elderly, or very thin
and to interact with society. patients, they require a 25G to 27G ½” needle.

45. Testing of the six cardinal fields of gaze evaluates 62. Before administering a drug, the nurse should
the function of all extraocular muscles and cranial identify the patient by checking the identification
nerves III, IV, and VI. band and asking the patient to state his name.

46. The six types of heart murmurs are graded from 1 63. To clean the skin before an injection, the nurse
to 6. A grade 6 heart murmur can be heard with the uses a sterile alcohol swab to wipe from the center of
stethoscope slightly raised from the chest. the site outward in a circular motion.
64. The nurse should inject heparin deep into 79. Keloid formation is an abnormality in healing
subcutaneous tissue at a 90-degree angle that’s characterized by overgrowth of scar tissue at
(perpendicular to the skin) to prevent skin irritation. the wound site.

65. If blood is aspirated into the syringe before an 80. The nurse should administer procaine penicillin by
I.M. injection, the nurse should withdraw the needle, deep I.M. injection in the upper outer portion of the
prepare another syringe, and repeat the procedure. buttocks in the adult or in the midlateral thigh in the
child. The nurse shouldn’t massage the injection site.
66. The nurse shouldn’t cut the patient’s hair without
written consent from the patient or an appropriate 81. An ascending colostomy drains fluid feces. A
relative. descending colostomy drains solid fecal matter.

67. If bleeding occurs after an injection, the nurse 82. A folded towel (scrotal bridge) can provide scrotal
should apply pressure until the bleeding stops. If support for the patient with scrotal edema caused by
bruising occurs, the nurse should monitor the site for vasectomy, epididymitis, or orchitis.
an enlarging hematoma.
83. When giving an injection to a patient who has a
68. When providing hair and scalp care, the nurse bleeding disorder, the nurse should use a small-gauge
should begin combing at the end of the hair and work needle and apply pressure to the site for 5 minutes
toward the head. after the injection.

69. The frequency of patient hair care depends on the 84. Platelets are the smallest and most fragile formed
length and texture of the hair, the duration of element of the blood and are essential for
hospitalization, and the patient’s condition. coagulation.

70. Proper function of a hearing aid requires careful 85. To insert a nasogastric tube, the nurse instructs
handling during insertion and removal, regular the patient to tilt the head back slightly and then
cleaning of the ear piece to prevent wax buildup, and inserts the tube. When the nurse feels the tube
prompt replacement of dead batteries. curving at the pharynx, the nurse should tell the
patient to tilt the head forward to close the trachea
71. The hearing aid that’s marked with a blue dot is and open the esophagus by swallowing. (Sips of
for the left ear; the one with a red dot is for the right water can facilitate this action.)
ear.
86. Families with loved ones in intensive care units
72. A hearing aid shouldn’t be exposed to heat or report that their four most important needs are to
humidity and shouldn’t be immersed in water. have their questions answered honestly, to be
assured that the best possible care is being provided,
73. The nurse should instruct the patient to avoid to know the patient’s prognosis, and to feel that there
using hair spray while wearing a hearing aid. is hope of recovery.

74. The five branches of pharmacology are 87. Double-bind communication occurs when the
pharmacokinetics, pharmacodynamics, verbal message contradicts the nonverbal message
pharmacotherapeutics, toxicology, and and the receiver is unsure of which message to
pharmacognosy. respond to.
75. The nurse should remove heel protectors every 8
hours to inspect the foot for signs of skin breakdown. 88. A nonjudgmental attitude displayed by a nurse
shows that she neither approves nor disapproves of
76. Heat is applied to promote vasodilation, which the patient.
reduces pain caused by inflammation.
89. Target symptoms are those that the patient finds
77. A sutured surgical incision is an example of most distressing.
healing by first intention (healing directly, without
granulation). 90. A patient should be advised to take aspirin on an
empty stomach, with a full glass of water, and should
78. Healing by secondary intention (healing by avoid acidic foods such as coffee, citrus fruits, and
granulation) is closure of the wound when granulation cola.
tissue fills the defect and allows reepithelialization to
occur, beginning at the wound edges and continuing 91. For every patient problem, there is a nursing
to the center, until the entire wound is covered. diagnosis; for every nursing diagnosis, there is a goal;
and for every goal, there are interventions designed
to make the goal a reality. The keys to answering 105. The family of a patient who has been diagnosed
examination questions correctly are identifying the as hearing impaired should be instructed to face the
problem presented, formulating a goal for the individual when they speak to him.
problem, and selecting the intervention from the
choices provided that will enable the patient to reach 106. Before instilling medication into the ear of a
that goal. patient who is up to age 3, the nurse should pull the
pinna down and back to straighten the eustachian
92. Fidelity means loyalty and can be shown as a tube.
commitment to the profession of nursing and to the
patient. 107. To prevent injury to the cornea when
administering eyedrops, the nurse should waste the
93. Administering an I.M. injection against the first drop and instill the drug in the lower conjunctival
patient’s will and without legal authority is battery. sac.

94. An example of a third-party payer is an insurance 108. After administering eye ointment, the nurse
company. should twist the medication tube to detach the
ointment.
95. The formula for calculating the drops per minute
for an I.V. infusion is as follows: (volume to be 109. When the nurse removes gloves and a mask,
infused × drip factor) ÷ time in minutes = she should remove the gloves first. They are soiled
drops/minute and are likely to contain pathogens.

96. On-call medication should be given within 5 110. Crutches should be placed 6″ (15.2 cm) in front
minutes of the call. of the patient and 6″ to the side to form a tripod
arrangement.
97. Usually, the best method to determine a patient’s
cultural or spiritual needs is to ask him. 111. Listening is the most effective communication
technique.
98. An incident report or unusual occurrence report
isn’t part of a patient’s record, but is an in-house 112. Before teaching any procedure to a patient, the
document that’s used for the purpose of correcting nurse must assess the patient’s current knowledge
the problem. and willingness to learn.

99. Critical pathways are a multidisciplinary guideline 113. Process recording is a method of evaluating
for patient care. one’s communication effectiveness.

100. When prioritizing nursing diagnoses, the 114. When feeding an elderly patient, the nurse
following hierarchy should be used: Problems should limit high-carbohydrate foods because of the
associated with the airway, those concerning risk of glucose intolerance.
breathing, and those related to circulation.
115. When feeding an elderly patient, essential foods
101. The two nursing diagnoses that have the highest should be given first.
priority that the nurse can assign are Ineffective
airway clearance and Ineffective breathing pattern. 116. Passive range of motion maintains joint mobility.
Resistive exercises increase muscle mass.
102. A subjective sign that a sitz bath has been
effective is the patient’s expression of decreased pain 117. Isometric exercises are performed on an
or discomfort. extremity that’s in a cast.

103. For the nursing diagnosis Deficient diversional 118. A back rub is an example of the gate-control
activity to be valid, the patient must state that he’s theory of pain.
“bored,” that he has “nothing to do,” or words to that
effect. 119. Anything that’s located below the waist is
considered unsterile; a sterile field becomes unsterile
104. The most appropriate nursing diagnosis for an when it comes in contact with any unsterile item; a
individual who doesn’t speak English is Impaired sterile field must be monitored continuously; and a
verbal communication related to inability to speak border of 1″ (2.5 cm) around a sterile field is
dominant language (English). considered unsterile.
120. A “shift to the left” is evident when the number 134. Milk is high in sodium and low in iron.
of immature cells (bands) in the blood increases to
fight an infection. 135. When a patient expresses concern about a
health-related issue, before addressing the concern,
121. A “shift to the right” is evident when the number the nurse should assess the patient’s level of
of mature cells in the blood increases, as seen in knowledge.
advanced liver disease and pernicious anemia.
136. The most effective way to reduce a fever is to
122. Before administering preoperative medication, administer an antipyretic, which lowers the
the nurse should ensure that an informed consent temperature set point.
form has been signed and attached to the patient’s
record. 137. When a patient is ill, it’s essential for the
members of his family to maintain communication
123. A nurse should spend no more than 30 minutes about his health needs.
per 8-hour shift providing care to a patient who has a
radiation implant. 138. Ethnocentrism is the universal belief that one’s
way of life is superior to others.
124. A nurse shouldn’t be assigned to care for more
than one patient who has a radiation implant. 139. When a nurse is communicating with a patient
through an interpreter, the nurse should speak to the
125. Long-handled forceps and a lead-lined container patient and the interpreter.
should be available in the room of a patient who has
a radiation implant. 140. In accordance with the “hot-cold” system used
by some Mexicans, Puerto Ricans, and other Hispanic
126. Usually, patients who have the same infection and Latino groups, most foods, beverages, herbs, and
and are in strict isolation can share a room. drugs are described as “cold.”

127. Diseases that require strict isolation include 141. Prejudice is a hostile attitude toward individuals
chickenpox, diphtheria, and viral hemorrhagic fevers of a particular group.
such as Marburg disease.
142. Discrimination is preferential treatment of
128. For the patient who abides by Jewish custom, individuals of a particular group. It’s usually discussed
milk and meat shouldn’t be served at the same meal. in a negative sense.

129. Whether the patient can perform a procedure 143. Increased gastric motility interferes with the
(psychomotor domain of learning) is a better indicator absorption of oral drugs.
of the effectiveness of patient teaching than whether
the patient can simply state the steps involved in the 144. The three phases of the therapeutic relationship
procedure (cognitive domain of learning). are orientation, working, and termination.

130. According to Erik Erikson, developmental stages 145. Patients often exhibit resistive and challenging
are trust versus mistrust (birth to 18 months), behaviors in the orientation phase of the therapeutic
autonomy versus shame and doubt (18 months to relationship.
age 3), initiative versus guilt (ages 3 to 5), industry
versus inferiority (ages 5 to 12), identity versus 146. Abdominal assessment is performed in the
identity diffusion (ages 12 to 18), intimacy versus following order: inspection, auscultation, palpation,
isolation (ages 18 to 25), generativity versus and percussion.
stagnation (ages 25 to 60), and ego integrity versus
despair (older than age 60). 147. When measuring blood pressure in a neonate,
the nurse should select a cuff that’s no less than one-
131. When communicating with a hearing impaired half and no more than two-thirds the length of the
patient, the nurse should face him. extremity that’s used.

132. An appropriate nursing intervention for the 148. When administering a drug by Z-track, the nurse
spouse of a patient who has a serious incapacitating shouldn’t use the same needle that was used to draw
disease is to help him to mobilize a support system. the drug into the syringe because doing so could stain
the skin.
133. Hyperpyrexia is extreme elevation in
temperature above 106° F (41.1° C).
149. Sites for intradermal injection include the inner terminal cancer and hypoglycemia, hypoglycemia is a
arm, the upper chest, and on the back, under the more immediate concern.
scapula.
160. E = Everything else. This category includes such
150. When evaluating whether an answer on an issues as writing an incident report and completing
examination is correct, the nurse should consider the patient chart. When evaluating needs, this
whether the action that’s described promotes category is never the highest priority.
autonomy (independence), safety, self-esteem, and a
sense of belonging. 161. When answering a question on an NCLEX
examination, the basic rule is “assess before action.”
151. When answering a question on the NCLEX The student should evaluate each possible answer
examination, the student should consider the cue (the carefully. Usually, several answers reflect the
stimulus for a thought) and the inference (the implementation phase of nursing and one or two
thought) to determine whether the inference is reflect the assessment phase. In this case, the best
correct. When in doubt, the nurse should select an choice is an assessment response unless a specific
answer that indicates the need for further information course of action is clearly indicated.
to eliminate ambiguity. For example, the patient
complains of chest pain (the stimulus for the thought) 162. Rule utilitarianism is known as the “greatest
and the nurse infers that the patient is having cardiac good for the greatest number of people” theory.
pain (the thought). In this case, the nurse hasn’t
confirmed whether the pain is cardiac. It would be 163. Egalitarian theory emphasizes that equal access
more appropriate to make further assessments. to goods and services must be provided to the less
fortunate by an affluent society.
152. Veracity is truth and is an essential component
of a therapeutic relationship between a health care 164. Active euthanasia is actively helping a person to
provider and his patient. die.

153. Beneficence is the duty to do no harm and the 165. Brain death is irreversible cessation of all brain
duty to do good. There’s an obligation in patient care function.
to do no harm and an equal obligation to assist the
patient. 166. Passive euthanasia is stopping the therapy that’s
sustaining life.
154. Nonmaleficence is the duty to do no harm.
167. A third-party payer is an insurance company.
155. Frye’s ABCDE cascade provides a framework for
prioritizing care by identifying the most important 168. Utilization review is performed to determine
treatment concerns. whether the care provided to a patient was
appropriate and cost-effective.
156. A = Airway. This category includes everything 169. A value cohort is a group of people who
that affects a patent airway, including a foreign experienced an out-of-the-ordinary event that shaped
object, fluid from an upper respiratory infection, and their values.
edema from trauma or an allergic reaction.
170. Voluntary euthanasia is actively helping a patient
157. B = Breathing. This category includes everything to die at the patient’s request.
that affects the breathing pattern, including
hyperventilation or hypoventilation and abnormal 171. Bananas, citrus fruits, and potatoes are good
breathing patterns, such as Korsakoff’s, Biot’s, or sources of potassium.
Cheyne-Stokes respiration.
172. Good sources of magnesium include fish, nuts,
158. C = Circulation. This category includes and grains.
everything that affects the circulation, including fluid
and electrolyte disturbances and disease processes 173. Beef, oysters, shrimp, scallops, spinach, beets,
that affect cardiac output. and greens are good sources of iron.

159. D = Disease processes. If the patient has no 174. Intrathecal injection is administering a drug
problem with the airway, breathing, or circulation, through the spine.
then the nurse should evaluate the disease processes,
giving priority to the disease process that poses the 175. When a patient asks a question or makes a
greatest immediate risk. For example, if a patient has statement that’s emotionally charged, the nurse
should respond to the emotion behind the statement 198. Primary prevention is true prevention. Examples
or question rather than to what’s being said or asked. are immunizations, weight control, and smoking
cessation.
176. The steps of the trajectory-nursing model are as
follows: 199. Secondary prevention is early detection.
177. Step 1: Identifying the trajectory phase Examples include purified protein derivative (PPD),
178. Step 2: Identifying the problems and breast self-examination, testicular self-examination,
establishing goals and chest X-ray.
179. Step 3: Establishing a plan to meet the goals
180. Step 4: Identifying factors that facilitate or 200. Tertiary prevention is treatment to prevent long-
hinder attainment of the goals term complications.
181. Step 5: Implementing interventions
182. Step 6: Evaluating the effectiveness of the 201. A patient indicates that he’s coming to terms
interventions with having a chronic disease when he says, “I’m
never going to get any better.”
183. A Hindu patient is likely to request a vegetarian
diet. 202. On noticing religious artifacts and literature on a
patient’s night stand, a culturally aware nurse would
184. Pain threshold, or pain sensation, is the initial ask the patient the meaning of the items.
point at which a patient feels pain.
203. A Mexican patient may request the intervention
185. The difference between acute pain and chronic of a curandero, or faith healer, who involves the
pain is its duration. family in healing the patient.

186. Referred pain is pain that’s felt at a site other 204. In an infant, the normal hemoglobin value is 12
than its origin. g/dl.

187. Alleviating pain by performing a back massage is 205. The nitrogen balance estimates the difference
consistent with the gate control theory. between the intake and use of protein.

188. Romberg’s test is a test for balance or gait. 206. Most of the absorption of water occurs in the
large intestine.
189. Pain seems more intense at night because the
patient isn’t distracted by daily activities. 207. Most nutrients are absorbed in the small
intestine.
190. Older patients commonly don’t report pain
because of fear of treatment, lifestyle changes, or 208. When assessing a patient’s eating habits, the
dependency. nurse should ask, “What have you eaten in the last 24
hours?”
191. No pork or pork products are allowed in a
Muslim diet. 209. A vegan diet should include an abundant supply
of fiber.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase the 210. A hypotonic enema softens the feces, distends
quality of life and the number of years of optimal the colon, and stimulates peristalsis.
health
194. Eliminate health disparities among different 211. First-morning urine provides the best sample to
segments of the population. measure glucose, ketone, pH, and specific gravity
values.
195. A community nurse is serving as a patient’s
advocate if she tells a malnourished patient to go to a 212. To induce sleep, the first step is to minimize
meal program at a local park. environmental stimuli.

196. If a patient isn’t following his treatment plan, the 213. Before moving a patient, the nurse should assess
nurse should first ask why. the patient’s physical abilities and ability to
understand instructions as well as the amount of
197. Falls are the leading cause of injury in elderly strength required to move the patient.
people.
214. To lose 1 lb (0.5 kg) in 1 week, the patient must 230. Abandonment is premature termination of
decrease his weekly intake by 3,500 calories treatment without the patient’s permission and
(approximately 500 calories daily). To lose 2 lb (1 kg) without appropriate relief of symptoms.
in 1 week, the patient must decrease his weekly
caloric intake by 7,000 calories (approximately 1,000 231. Values clarification is a process that individuals
calories daily). use to prioritize their personal values.

215. To avoid shearing force injury, a patient who is 232. Distributive justice is a principle that promotes
completely immobile is lifted on a sheet. equal treatment for all.

216. To insert a catheter from the nose through the 233. Milk and milk products, poultry, grains, and fish
trachea for suction, the nurse should ask the patient are good sources of phosphate.
to swallow.
234. The best way to prevent falls at night in an
217. Vitamin C is needed for collagen production. oriented, but restless, elderly patient is to raise the
side rails.
218. Only the patient can describe his pain accurately.
235. By the end of the orientation phase, the patient
219. Cutaneous stimulation creates the release of should begin to trust the nurse.
endorphins that block the transmission of pain stimuli.
236. Falls in the elderly are likely to be caused by
220. Patient-controlled analgesia is a safe method to poor vision.
relieve acute pain caused by surgical incision,
traumatic injury, labor and delivery, or cancer. 237. Barriers to communication include language
deficits, sensory deficits, cognitive impairments,
221. An Asian American or European American structural deficits, and paralysis.
typically places distance between himself and others
when communicating. 238. The three elements that are necessary for a fire
are heat, oxygen, and combustible material.
222. The patient who believes in a scientific, or
biomedical, approach to health is likely to expect a 239. Sebaceous glands lubricate the skin.
drug, treatment, or surgery to cure illness.
240. To check for petechiae in a dark-skinned patient,
223. Chronic illnesses occur in very young as well as the nurse should assess the oral mucosa.
middle-aged and very old people.
241. To put on a sterile glove, the nurse should pick
224. The trajectory framework for chronic illness up the first glove at the folded border and adjust the
states that preferences about daily life activities affect fingers when both gloves are on.
treatment decisions.
242. To increase patient comfort, the nurse should let
225. Exacerbations of chronic disease usually cause the alcohol dry before giving an intramuscular
the patient to seek treatment and may lead to injection.
hospitalization.
243. Treatment for a stage 1 ulcer on the heels
226. School health programs provide cost-effective includes heel protectors.
health care for low-income families and those who
have no health insurance. 244. Seventh-Day Adventists are usually vegetarians.

227. Collegiality is the promotion of collaboration, 245. Endorphins are morphine-like substances that
development, and interdependence among members produce a feeling of well-being.
of a profession.
246. Pain tolerance is the maximum amount and
228. A change agent is an individual who recognizes a duration of pain that an individual is willing to endure.
need for change or is selected to make a change
within an established entity, such as a hospital. PSYCHIATRIC

229. The patients’ bill of rights was introduced by the 1. According to Kübler-Ross, the five stages of
American Hospital Association. death and dying are denial, anger, bargaining,
depression, and acceptance.
2. Flight of ideas is an alteration in thought drives. (Remember i for instinctual and d for
processes that’s characterized by skipping from drive.)
one topic to another, unrelated topic. 19. Denial is the defense mechanism used by a
3. La belle indifférence is the lack of concern patient who denies the reality of an event.
for a profound disability, such as blindness or 20. In a psychiatric setting, seclusion is used to
paralysis that may occur in a patient who has a reduce overwhelming environmental stimulation,
conversion disorder. protect the patient from self-injury or injury to
4. Moderate anxiety decreases a person’s ability others, and prevent damage to hospital
to perceive and concentrate. The person is property. It’s used for patients who don’t
selectively inattentive (focuses on immediate respond to less restrictive interventions.
concerns), and the perceptual field narrows. Seclusion controls external behavior until the
5. A patient who has a phobic disorder uses patient can assume self-control and helps the
self-protective avoidance as an ego defense patient to regain self-control.
mechanism. 21. Tyramine-rich food, such as aged cheese,
6. In a patient who has anorexia nervosa, the chicken liver, avocados, bananas,
highest treatment priority is correction of meat tenderizer, salami, bologna, Chianti wine,
nutritional and electrolyte imbalances. and beer may cause severe hypertension in a
7. A patient who is taking lithium must undergo patient who takes a monoamine oxidase
regular (usually once a month) monitoring of inhibitor.
the blood lithium level because the margin 22. A patient who takes a monoamine oxidase
between therapeutic and toxic levels is narrow. inhibitor should be weighed biweekly and
A normal laboratory value is 0.5 to 1.5 mEq/L. monitored for suicidal tendencies.
8. Early signs and symptoms of alcohol 23. If the patient who takes a monoamine
withdrawal include anxiety, anorexia, tremors, oxidase inhibitor has palpitations, headaches, or
and insomnia. They may begin up to 8 hours severe orthostatic hypotension, the nurse
after the last alcohol intake. should withhold the drug and notify the
9. Al-Anon is a support group for families of physician.
alcoholics. 24. Common causes of child abuse are poor
10. The nurse shouldn’t administer impulse control by the parents and the lack of
chlorpromazine (Thorazine) to a patient who knowledge of growth and development.
has ingested alcohol because it may cause 25. The diagnosis of Alzheimer’s disease is based
oversedation and respiratory depression. on clinical findings of two or more cognitive
11. Lithium toxicity can occur when sodium and deficits, progressive worsening of memory, and
fluid intake are insufficient, causing lithium the results of a neuropsychological test.
retention. 26. Memory disturbance is a classic sign of
12. An alcoholic who achieves sobriety is called a Alzheimer’s disease.
recovering alcoholic because no cure for 27. Thought blocking is loss of the train of
alcoholism exists. thought because of a defect in mental
13. According to Erikson, the school-age child processing.
(ages 6 to 12) is in the industry-versus- 28. A compulsion is an irresistible urge to
inferiority stage ofpsychosocial development. perform an irrational act, such as walking in a
14. When caring for a depressed patient, the clockwise circle before leaving a room or
nurse’s first priority is safety because of the washing the hands repeatedly.
increased risk of suicide. 29. A patient who has a chosen method and a
15. Echolalia is parrotlike repetition of another plan to commit suicide in the next 48 to 72
person’s words or phrases. hours is at high risk for suicide.
16. According to psychoanalytic theory, the ego 30. The therapeutic serum level for lithium is 0.5
is the part of the psyche that controls internal to 1.5 mEq/L.
demands and interacts with the outside world at 31. Phobic disorders are treated with
the conscious, preconscious, and unconscious desensitization therapy, which gradually exposes
levels. a patient to an anxiety-producing stimulus.
17. According to psychoanalytic theory, the 32. Dysfunctional grieving is absent or prolonged
superego is the part of the psyche that’s grief.
composed of morals, values, and ethics. It 33. During phase I of the nurse-patient
continually evaluates thoughts and actions, relationship (beginning, or orientation, phase),
rewarding the good and punishing the bad. the nurse obtains an initial history and the nurse
(Think of the superego as the “supercop” of the and the patient agree to a contract.
unconscious.) 34. During phase II of the nurse-patient
18. According to psychoanalytic theory, the id is relationship (middle, or working, phase), the
the part of the psyche that contains instinctual patient discusses his problems, behavioral
 changes occur, and self-defeating behavior is allowing the participant to recreate and enact
resolved or reduced. scenes to gain insight and to practice new skills.
35. During phase III of the nurse-patient 54. Psychodrama is a therapeutic technique
relationship (termination, or resolution, phase), that’s used with groups to help participants gain
the nurse terminates the therapeutic new perception and self-awareness by acting
relationship and gives the patient positive out their own or assigned problems.
feedback on his accomplishments. 55. A patient who is taking disulfiram (Antabuse)
36. According to Freud, a person between ages must avoid ingesting products that contain
12 and 20 is in the genital stage, during which alcohol, such as cough syrup, fruitcake, and
he learns independence, has an increased sauces and soups made with cooking wine.
interest in members of the opposite sex, and 56. A patient who is admitted to a psychiatric
establishes an identity. hospital involuntarily loses the right to sign out
37. According to Erikson, the identity-versus-role against medical advice.
confusion stage occurs between ages 12 and 57. “People who live in glass houses shouldn’t
20. throw stones” and “A rolling stone gathers no
38. Tolerance is the need for increasing amounts moss” are examples of proverbs used during a
of a substance to achieve an effect that formerly psychiatric interview to determine a patient’s
was achieved with lesser amounts. ability to think abstractly. (Schizophrenic
39. Suicide is the third leading cause of death patients think in concrete terms and might
among white teenagers. interpret the glass house proverb as “If you
40. Most teenagers who kill themselves made a throw a stone in a glass house, the house will
previous suicide attempt and left telltale signs of break.”)
their plans. 58. Signs of lithium toxicity include diarrhea,
41. In Erikson’s stage of generativity versus tremors, nausea, muscle weakness, ataxia, and
despair, generativity (investment of the self in confusion.
the interest of the larger community) is 59. A labile affect is characterized by rapid shifts
expressed through procreation, work, of emotions and mood.
community service, and creative endeavors. 60. Amnesia is loss of memory from an organic
42. Alcoholics Anonymous recommends a 12- or inorganic cause.
step program to achieve sobriety. 61. A person who has borderline personality
43. Signs and symptoms of anorexia nervosa disorder is demanding and judgmental in
include amenorrhea, excessive weight loss, interpersonal relationships and will attempt to
lanugo (fine body hair),abdominal distention, split staff by pointing to discrepancies in the
and electrolyte disturbances. treatment plan.
44. A serum lithium level that exceeds 2.0 62. Disulfiram (Antabuse) shouldn’t be taken
mEq/L is considered toxic. concurrently with metronidazole (Flagyl)
45. Public Law 94-247 (Child Abuse and Neglect because they may interact and cause a
Act of 1973) requires reporting of suspected psychotic reaction.
cases of child abuse to child protection services. 63. In rare cases, electroconvulsive therapy
46. The nurse should suspect sexual abuse in a causes arrhythmias and death.
young child who has blood in the feces or urine, 64. A patient who is scheduled for
penile or vaginal discharge, genital trauma that electroconvulsive therapy should receive nothing
isn’t readily explained, or a sexually transmitted by mouth after midnight to prevent aspiration
disease. while under anesthesia.
47. An alcoholic uses alcohol to cope with the 65. Electroconvulsive therapy is normally used
stresses of life. for patients who have severe depression that
48. The human personality operates on three doesn’t respond to drug therapy.
levels: conscious, preconscious, and 66. For electroconvulsive therapy to be effective,
unconscious. the patient usually receives 6 to 12 treatments
49. Asking a patient an open-ended question is at a rate of 2 to 3 per week.
one of the best ways to elicit or clarify 67. During the manic phase of bipolar affective
information. disorder, nursing care is directed at slowing the
50. The diagnosis of autism is often made when patient down because the patient may die as a
a child is between ages 2 and 3. result of self-induced exhaustion or injury.
51. Defense mechanisms protect the personality 68. For a patient with Alzheimer’s disease, the
by reducing stress and anxiety. nursing care plan should focus on safety
52. Suppression is voluntary exclusion of stress- measures.
producing thoughts from the consciousness. 69. After sexual assault, the patient’s needs are
53. In psychodrama, life situations are the primary concern, followed by medicolegal
approximated in a structured environment, considerations.
70. Patients who are in a maintenance program 91. The nurse should encourage an angry
for narcotic abstinence syndrome receive 10 to patient to follow a physical exercise program as
40 mg of methadone (Dolophine) in a single one of the ways to ventilate feelings.
daily dose and are monitored to ensure that the 92. Depression is clinically significant if it’s
drug is ingested. characterized by exaggerated feelings of
71. Stress management is a short-range goal of sadness, melancholy, dejection, worthlessness,
psychotherapy. and hopelessness that are inappropriate or out
72. The mood most often experienced by a of proportion to reality.
patient with organic brain syndrome is 93. Free-floating anxiety is anxiousness with
irritability. generalized apprehension and pessimism for
73. Creative intuition is controlled by the right unknown reasons.
side of the brain. 94. In a patient who is experiencing intense
74. Methohexital (Brevital) is the general anxiety, the fight-or-flight reaction (alarm
anesthetic that’s administered to patients who reflex) may take over.
are scheduled for electroconvulsive therapy. 95. Confabulation is the use of imaginary
75. The decision to use restraints should be experiences or made-up information to fill
based on the patient’s safety needs. missing gaps of memory.
76. Diphenhydramine (Benadryl) relieves the 96. When starting a therapeutic relationship with
extrapyramidal adverse effects of psychotropic a patient, the nurse should explain that the
drugs. purpose of the therapy is to produce a positive
77. In a patient who is stabilized on lithium change.
(Eskalith) therapy, blood lithium levels should be 97. A basic assumption of psychoanalytic theory
checked 8 to 12 hours after the first dose, then is that all behavior has meaning.
two or three times weekly during the first 98. Catharsis is the expression of deep feelings
month. Levels should be checked weekly to and emotions.
monthly during maintenance therapy. 99. According to the pleasure principle, the
78. The primary purpose of psychotropic drugs is psyche seeks pleasure and avoids unpleasant
to decrease the patient’s symptoms, which experiences, regardless of the consequences.
improves function and increases compliance 100. A patient who has a conversion disorder
with therapy. resolves a psychological conflict through the loss
79. Manipulation is a maladaptive method of of a specific physical function (for example,
meeting one’s needs because it disregards the paralysis, blindness, or inability to swallow).
needs and feelings of others. This loss of function is involuntary, but
80. If a patient has symptoms of lithium toxicity, diagnostic tests show no organic cause.
the nurse should withhold one dose and call the 101. Chlordiazepoxide (Librium) is the drug of
physician. choice for treating alcohol withdrawal
81. A patient who is taking lithium (Eskalith) for symptoms.
bipolar affective disorder must maintain a 102. For a patient who is at risk for alcohol
balanced diet with adequate salt intake. withdrawal, the nurse should assess the pulse
82. A patient who constantly seeks approval or rate and blood pressure every 2 hours for the
assistance from staff members and other first 12 hours, every 4 hours for the next 24
patients is demonstrating dependent behavior. hours, and every 6 hours thereafter (unless the
83. Alcoholics Anonymous advocates total patient’s condition becomes unstable).
abstinence from alcohol. 103. Alcohol detoxification is most successful
84. Methylphenidate (Ritalin) is the drug of when carried out in a structured environment by
choice for treating attention deficit hyperactivity a supportive, nonjudgmental staff.
disorder in children. 104. The nurse should follow these guidelines
85. Setting limits is the most effective way to when caring for a patient who is experiencing
control manipulative behavior. alcohol withdrawal: Maintain a calm
86. Violent outbursts are common in a patient environment, keep intrusions to a minimum,
who has borderline personality disorder. speak slowly and calmly, adjust lighting to
87. When working with a depressed patient, the prevent shadows and glare, call the patient by
nurse should explore meaningful losses. name, and have a friend or family member stay
88. An illusion is a misinterpretation of an actual with the patient, if possible.
environmental stimulus. 105. The therapeutic regimen for an alcoholic
89. Anxiety is nonspecific; fear is specific. patient includes folic acid, thiamine, and
90. Extrapyramidal adverse effects are common multivitamin supplements as well as adequate
in patients who take antipsychotic drugs. food and fluids.
106. A patient who is addicted to opiates (drugs
derived from poppy seeds, such as heroin and
 morphine) typically experiences withdrawal marked by hallucinations, confabulation,
symptoms within 12 hours after the last dose. amnesia, and disturbances of orientation.
The most severe symptoms occur within 48 124. A patient with antisocial personality disorder
hours and decrease over the next 2 weeks. often engages in confrontations with authority
107. Reactive depression is a response to a figures, such as police, parents, and school
specific life event. officials.
108. Projection is the unconscious assigning of a 125. A patient with paranoid personality disorder
thought, feeling, or action to someone or exhibits suspicion, hypervigilance, and hostility
something else. toward others.
109. Sublimation is the channeling of 126. Depression is the most common psychiatric
unacceptable impulses into socially acceptable disorder.
behavior. 127. Adverse reactions to tricyclic antidepressant
110. Repression is an unconscious defense drugs include tachycardia, orthostatic
mechanism whereby unacceptable or painful hypotension, hypomania, lowered seizure
thoughts, impulses, memories, or feelings are threshold, tremors, weight gain, problems with
pushed from the consciousness or forgotten. erections or orgasms, and anxiety.
111. Hypochondriasis is morbid anxiety about 128. The Minnesota Multiphasic Personality
one’s health associated with various symptoms Inventory consists of 550 statements for the
that aren’t caused by organic disease. subject to interpret. It assesses personality and
112. Denial is a refusal to acknowledge feelings, detects disorders, such as depression and
thoughts, desires, impulses, or external facts schizophrenia, in adolescents and adults.
that are consciously intolerable. 129. Organic brain syndrome is the most common
113. Reaction formation is the avoidance of form of mental illness in elderly patients.
anxiety through behavior and attitudes that are 130. A person who has an IQ of less than 20 is
the opposite of repressed impulses and drives. profoundly retarded and is considered a total-
114. Displacement is the transfer of unacceptable care patient.
feelings to a more acceptable object. 131. Reframing is a therapeutic technique that’s
115. Regression is a retreat to an earlier used to help depressed patients to view a
developmental stage. situation in alternative ways.
116. According to Erikson, an older adult (age 65 132. Fluoxetine (Prozac), sertraline (Zoloft), and
or older) is in the developmental stage of paroxetine (Paxil) are serotonin reuptake
integrity versus despair. inhibitors used to treat depression.
117. Family therapy focuses on the family as a 133. The early stage of Alzheimer’s disease lasts 2
whole rather than the individual. Its major to 4 years. Patients have inappropriate affect,
objective is to reestablish rational transient paranoia, disorientation to time,
communication between family members. memory loss, careless dressing, and impaired
118. When caring for a patient who is hostile or judgment.
angry, the nurse should attempt to remain calm, 134. The middle stage of Alzheimer’s disease lasts
listen impartially, use short sentences, and 4 to 7 years and is marked by profound
speak in a firm, quiet voice. personality changes, loss of independence,
119. Ritualism and negativism are typical toddler disorientation, confusion, inability to recognize
behaviors. They occur during the developmental family members, and nocturnal restlessness.
stage identified by Erikson as autonomy versus 135. The last stage of Alzheimer’s disease occurs
shame and doubt. during the final year of life and is characterized
120. Circumstantiality is a disturbance in by a blank facial expression, seizures, loss of
associated thought and speech patterns in appetite, emaciation, irritability, and total
which a patient gives unnecessary, minute dependence.
details and digresses into inappropriate 136. Threatening a patient with an injection for
thoughts that delay communication of central failing to take an oral drug is an example of
ideas and goal achievement. assault.
121. Idea of reference is an incorrect belief that 137. Reexamination of life goals is a major
the statements or actions of others are related developmental task during middle adulthood.
to oneself. 138. Acute alcohol withdrawal causes anorexia,
122. Group therapy provides an opportunity for insomnia, headache, and restlessness and
each group member to examine interactions, escalates to a syndrome that’s characterized by
learn and practice successful interpersonal agitation, disorientation, vivid hallucinations,
communication skills, and explore emotional and tremors of the hands, feet, legs, and
conflicts. tongue.
123. Korsakoff’s syndrome is believed to be a
chronic form of Wernicke’s encephalopathy. It’s
139. In a hospitalized alcoholic, alcohol 156. A patient who is taking lithium should stop
withdrawal delirium most commonly occurs 3 to taking the drug and call his physician if he
4 days after admission. experiences vomiting, drowsiness, or muscle
140. Confrontation is a communication technique weakness.
in which the nurse points out discrepancies 157. The patient who is taking a monoamine
between the patient’s words and his nonverbal oxidase inhibitor for depression can include
behaviors. cottage cheese, cream cheese, yogurt, and sour
141. For a patient with substance-induced cream in his diet.
delirium, the time of drug ingestion can help to 158. Sensory overload is a state in which sensory
determine whether the drug can be evacuated stimulation exceeds the individual’s capacity to
from the body. tolerate or process it.
142. Treatment for alcohol withdrawal may 159. Symptoms of sensory overload include a
include administration of I.V. glucose for feeling of distress and hyperarousal with
hypoglycemia, I.V. fluid containing thiamine and impaired thinking and concentration.
other B vitamins, and antianxiety, antidiarrheal, 160. In sensory deprivation, overall sensory input
anticonvulsant, and antiemetic drugs. is decreased.
143. The alcoholic patient receives thiamine to 161. A sign of sensory deprivation is a decrease in
help prevent peripheral neuropathy and stimulation from the environment or from within
Korsakoff’s syndrome. oneself, such as daydreaming, inactivity,
144. Alcohol withdrawal may precipitate seizure sleeping excessively, and reminiscing.
activity because alcohol lowers the seizure 162. The three stages of general adaptation
threshold in some people. syndrome are alarm, resistance, and
145. Paraphrasing is an active listening technique exhaustion.
in which the nurse restates what the patient has 163. A maladaptive response to stress is drinking
just said. alcohol or smoking excessively.
146. A patient with Korsakoff’s syndrome may use 164. Hyperalertness and the startle reflex are
confabulation (made up information) to cover characteristics of posttraumatic stress disorder.
memory lapses or periods of amnesia. 165. A treatment for a phobia is desensitization, a
147. People with obsessive-compulsive disorder process in which the patient is slowly exposed
realize that their behavior is unreasonable, but to the feared stimuli.
are powerless to control it. 166. Symptoms of major depressive disorder
148. When witnessing psychiatric patients who include depressed mood, inability to experience
are engaged in a threatening confrontation, the pleasure, sleep disturbance, appetite changes,
nurse should first separate the two individuals. decreased libido, and feelings of worthlessness.
149. Patients with anorexia nervosa or bulimia 167. Clinical signs of lithium toxicity are nausea,
must be observed during meals and for some vomiting, and lethargy.
time afterward to ensure that they don’t purge 168. Asking too many “why” questions yields
what they have eaten. scant information and may overwhelm a
150. Transsexuals believe that they were born the psychiatric patient and lead to stress and
wrong gender and may seek hormonal or withdrawal.
surgical treatment to change their gender. 169. Remote memory may be impaired in the late
151. Fugue is a dissociative state in which a stages of dementia.
person leaves his familiar surroundings, 170. According to the DSM-IV, bipolar II disorder
assumes a new identity, and has amnesia about is characterized by at least one manic episode
his previous identity. (It’s also described as that’s accompanied by hypomania.
“flight from himself.”) 171. The nurse can use silence and active
152. In a psychiatric setting, the patient should listening to promote interactions with a
be able to predict the nurse’s behavior and depressed patient.
expect consistent positive attitudes and 172. A psychiatric patient with a substance abuse
approaches. problem and a major psychiatric disorder has a
153. When establishing a schedule for a one-to- dual diagnosis.
one interaction with a patient, the nurse should 173. When a patient is readmitted to a mental
state how long the conversation will last and health unit, the nurse should assess compliance
then adhere to the time limit. with medication orders.
154. Thought broadcasting is a type of delusion in 174. Alcohol potentiates the effects of tricyclic
which the person believes that his thoughts are antidepressants.
being broadcast for the world to hear. 175. Flight of ideas is movement from one topic
155. Lithium should be taken with food. A patient to another without any discernible connection.
who is taking lithium shouldn’t restrict his 176. Conduct disorder is manifested by extreme
sodium intake. behavior, such as hurting people and animals.
177. During the “tension-building” phase of an 198. Agoraphobia is fear of open spaces.
abusive relationship, the abused individual feels 199. A person who has paranoid personality
helpless. disorder projects hostilities onto others.
178. In the emergency treatment of an alcohol- 200. To assess a patient’s judgment, the nurse
intoxicated patient, determining the blood- should ask the patient what he would do if he
alcohol level is paramount in determining the found a stamped, addressed envelope. An
amount of medication that the patient needs. appropriate response is that he would mail the
179. Side effects of the antidepressant fluoxetine envelope.
(Prozac) include diarrhea, decreased libido, 201. After electroconvulsive therapy, the patient
weight loss, and dry mouth. should be monitored for post-shock amnesia.
180. Before electroconvulsive therapy, the patient 202. A mother who continues to perform
is given the skeletal muscle relaxant cardiopulmonary resuscitation after a physician
succinylcholine (Anectine) by I.V. pronounces a child dead is showing denial.
administration. 203. Transvestism is a desire to wear clothes
181. When a psychotic patient is admitted to an usually worn by members of the opposite sex.
inpatient facility, the primary concern is safety, 204. Tardive dyskinesia causes excessive blinking
followed by the establishment of trust. and unusual movement of the tongue, and
182. An effective way to decrease the risk of involuntary sucking and chewing.
suicide is to make a suicide contract with the 205. Trihexyphenidyl (Artane) and benztropine
patient for a specified period of time. (Cogentin) are administered to counteract
183. A depressed patient should be given extrapyramidal adverse effects.
sufficient portions of his favorite foods, but 206. To prevent hypertensive crisis, a patient who
shouldn’t be overwhelmed with too much food. is taking a monoamine oxidase inhibitor should
184. The nurse should assess the depressed avoid consuming aged cheese, caffeine, beer,
patient for suicidal ideation. yeast, chocolate, liver, processed foods, and
185. Delusional thought patterns commonly occur monosodium glutamate.
during the manic phase of bipolar disorder. 207. Extrapyramidal symptoms include
186. Apathy is typically observed in patients who parkinsonism, dystonia, akathisia (“ants in the
have schizophrenia. pants”), and tardive dyskinesia.
187. Manipulative behavior is characteristic of a 208. One theory that supports the use of
patient who has passive– aggressive personality electroconvulsive therapy suggests that it
disorder. “resets” the brain circuits to allow normal
188. When a patient who has schizophrenia function.
begins to hallucinate, the nurse should redirect 209. A patient who has obsessive-compulsive
the patient to activities that are focused on the disorder usually recognizes the senselessness of
here and now. his behavior but is powerless to stop it (ego-
189. When a patient who is receiving an dystonia).
antipsychotic drug exhibits muscle rigidity and 210. In helping a patient who has been abused,
tremors, the nurse should administer an physical safety is the nurse’s first priority.
antiparkinsonian drug (for example, Cogentin or 211. Pemoline (Cylert) is used to treat attention
Artane) as ordered. deficit hyperactivity disorder (ADHD).
190. A patient who is receiving lithium (Eskalith) 212. Clozapine (Clozaril) is contraindicated in
therapy should report diarrhea, vomiting, pregnant women and in patients who have
drowsiness, muscular weakness, or lack of severe granulocytopenia or severe central
coordination to the physician immediately. nervous system depression.
191. The therapeutic serum level of lithium 213. Repression, an unconscious process, is the
(Eskalith) for maintenance is 0.6 to 1.2 mEq/L. inability to recall painful or unpleasant thoughts
192. Obsessive-compulsive disorder is an anxiety- or feelings.
related disorder. 214. Projection is shifting of unwanted
193. Al-Anon is a self-help group for families of characteristics or shortcomings to others
alcoholics. (scapegoat).
194. Desensitization is a treatment for phobia, or 215. Hypnosis is used to treat psychogenic
irrational fear. amnesia.
195. After electroconvulsive therapy, the patient 216. Disulfiram (Antabuse) is administered orally
is placed in the lateral position, with the head as an aversion therapy to treat alcoholism.
turned to one side. 217. Ingestion of alcohol by a patient who is
196. A delusion is a fixed false belief. taking disulfiram (Antabuse) can cause severe
197. Giving away personal possessions is a sign of reactions, including nausea and vomiting, and
suicidal ideation. Other signs include writing a may endanger the patient’s life.
suicide note or talking about suicide.
 218. Improved concentration is a sign that lithium
is taking effect.
219. Behavior modification, including time-outs,
token economy, or a reward system, is a
treatment for attention deficit hyperactivity
disorder.
220. For a patient who has anorexia nervosa, the
nurse should provide support at mealtime and
record the amount the patient eats.
221. A significant toxic risk associated with
clozapine (Clozaril) administration is blood
dyscrasia.
222. Adverse effects of haloperidol (Haldol)
administration include drowsiness; insomnia;
weakness; headache; and extrapyramidal
symptoms, such as akathisia, tardive dyskinesia,
and dystonia.
223. Hypervigilance and déjà vu are signs of
posttraumatic stress disorder (PTSD).
224. A child who shows dissociation has probably
been abused.
225. Confabulation is the use of fantasy to fill in
gaps of memory.