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NURSING
REVIEWER

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They are more pronounced
during expiration than during inspiration
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Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach
through the mouth)
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According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex,
activity, and comfort) have the highest priority
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The safest and surest way to verify a patient’s identity is to check the identification band on
his wrist
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In the therapeutic environment, the patient’s safety is the primary concern
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Fluid oscillation in the tubing of a chest drainage system indicates that the system is working
properly
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The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler
position
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The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery
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It requires a needle that’s 1″ (2
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(R) Remove the patient
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(C) Attempt to contain the fire by closing the door
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The nurse obtains assessment data through the health history, physical
examination, and review of diagnostic studies
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The appropriate needle size for insulin injection is 25G and 5/8″ long
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Residual urine is urine that remains in the bladder after voiding
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1 m) from the chart
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For a geriatric patient or one who is extremely ill, the ideal room temperature is 66° to 76° F
(18
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4° C)
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Normal room humidity is 30% to 60%
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Hand washing is the single best method of limiting the spread of microorganisms
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A milliequivalent is
the number of milligrams per 100 milliliters of a solution
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Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the
destructive phase)
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The basal metabolic rate is the amount of energy needed to maintain essential body
functions
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Smaller amounts are metabolized by the kidneys
and lungs
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Petechiae are tiny, round, purplish red spots that appear on the skin and mucous
membranes as a result of intradermal or submucosal hemorrhage
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Purpura is a purple discoloration of the skin that’s caused by blood extravasation
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According to the standard precautions recommended by the Centers for Disease Control
and Prevention, the nurse shouldn’t recap needles after use
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When caring for any patient, the nurse should follow standard precautions for handling blood
and body fluids
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Potassium (K+) is the most abundant cation in intracellular fluid
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In the four-point, or alternating, gait, the patient first moves the right crutch followed by the
left foot and then the left crutch followed by the right foot
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In the three-point gait, the patient moves two crutches and the affected leg simultaneously
and then moves the unaffected leg
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In the two-point gait, the patient moves the right leg and the left crutch simultaneously and
then moves the left leg and the right crutch simultaneously
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The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include
thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12)
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When being weighed, an adult patient should be lightly dressed and shoeless
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Before taking an adult’s temperature orally, the nurse should ensure that the patient hasn’t
smoked or consumed hot or cold substances in the previous 15 minutes
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The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder,
anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery
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In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a
vagal response and lead to vasodilation and decreased cardiac output
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When recording pulse amplitude and rhythm, the nurse should use these descriptive
measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily
palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not
detectable)
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The intraoperative period begins when a patient is transferred to the operating room bed
and ends when the patient is admitted to the postanesthesia care unit
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Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing
a restful environment, may decrease the patient’s need for analgesics or may enhance their
effectiveness
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On the morning of surgery, the nurse should ensure that the informed consent form has been
signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower
with antimicrobial soap, has had mouth care (without swallowing the water), has removed
common jewelry, and has received preoperative medication as prescribed; and that vital
signs have been taken and recorded
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5 cm) above the antecubital fossa
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When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and
then apply the ointment from the inner canthus to the outer canthus
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The nurse should use a leg cuff to measure blood pressure in an obese patient
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If a blood pressure cuff is applied too loosely, the reading will be falsely lowered
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Ptosis is drooping of the eyelid
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A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain
damage because it can move the patient gradually from a horizontal to a vertical (upright)
position
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To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and
add 2″ (5 cm) to that measurement
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To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel
upward when the vessel’s lumen is larger than the needle and turn it downward when the
lumen is only slightly larger than the needle
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To move a patient to the edge of the bed for transfer, the nurse should follow these steps:
(1) Move the patient’s head and shoulders toward the edge of the bed
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(3) Place both arms well
under the patient’s hips, and (4) straighten the back while moving the patient toward the
edge of the bed
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When being measured for crutches, a patient should wear shoes
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The nurse should attach a restraint to the part of the bed frame that moves with the head,
not to the mattress or side rails
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Hertz (Hz) is the unit of measurement of sound frequency
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The mist in a mist tent should never become so dense that it obscures clear visualization of
the patient’s respiratory pattern
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To administer heparin subcutaneously, the nurse should follow these steps: Clean, but don’t
rub, the site with alcohol
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Hold the
shaft of the needle in a dart position
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Firmly depress the plunger, but don’t aspirate
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Withdraw the needle gently at the angle of insertion
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Double hearing
protection is required if it exceeds 104 dB
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Prothrombin, a clotting factor, is produced in the liver
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If a patient is menstruating when a urine sample is collected, the nurse should note this
on the laboratory request
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During lumbar puncture, the nurse must note the initial intracranial pressure and the color
of the cerebrospinal fluid
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If a patient can’t cough to provide a sputum sample for culture, a heated aerosol
treatment can be used to help to obtain a sample
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If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be
instilled first
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An EEG identifies normal and abnormal brain waves
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When leaving an isolation room, the nurse should remove her gloves before her mask
because fewer pathogens are on the mask
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Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective
means of traction
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The total parenteral nutrition solution should be stored in a refrigerator and removed 30
to 60 minutes before use
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When withdrawing the catheter, the nurse should apply intermittent
suction for no more than 15 seconds and use a slight twisting motion
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A low-residue diet includes such foods as roasted chicken, rice, and pasta
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A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate the
rectal mucosa and cause loss of sphincter control
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A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate the
rectal mucosa and cause loss of sphincter control
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A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest,
abdomen, back, legs, perineum
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To prevent injury when lifting and moving a patient, the nurse should primarily use the
upper leg muscles
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Patient preparation for cholecystography includes ingestion of a contrast medium and a
low-fat evening meal
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While an occupied bed is being changed, the patient should be covered with a bath
blanket to promote warmth and prevent exposure
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Anticipatory grief is mourning that occurs for an extended time when the patient realizes
that death is inevitable
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The following foods can alter the color of the feces: beets (red), cocoa (dark red or
brown), licorice (black), spinach (green), and meat protein (dark brown)
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When preparing for a skull X-ray, the patient should remove all jewelry and dentures
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The fight-or-flight response is a sympathetic nervous system response
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Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest
pneumonia
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Wheezing is an abnormal, high-pitched breath sound that’s accentuated on expiration
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Wax or a foreign body in the ear should be flushed out gently by irrigation with warm
saline solution
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If a patient complains that his hearing aid is “not working,” the nurse should check the
switch first to see if it’s turned on and then check the batteries
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The nurse should grade hyperactive biceps and triceps reflexes as +4
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In a postoperative patient, forcing fluids helps prevent constipation
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If two eye medications are prescribed for twice-daily instillation, they should be
administered 5 minutes apart
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A nurse must provide care in accordance with standards of care established by the
American Nurses Association, state regulations, and facility policy
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The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat
needed to raise the temperature of 1 kilogram of water 1° C
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As nutrients move through the body, they undergo ingestion, digestion, absorption,
transport, cell metabolism, and excretion
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The body metabolizes alcohol at a fixed rate, regardless of serum concentration
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In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2
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These decisions are based on the patient’s wishes and views on quality of
life
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The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the
previous 8 hours) and as needed with normal saline solution to maintain patency
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Quality assurance is a method of determining whether nursing actions and practices
meet established standards
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The five rights of medication administration are the right patient, right drug, right dose,
right route of administration, and right time
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The evaluation phase of the nursing process is to determine whether nursing interventions
have enabled the patient to meet the desired goals
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Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin
should be used to relieve acute anginal attacks
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The implementation phase of the nursing process involves recording the patient’s
response to the nursing plan, putting the nursing plan into action, delegating specific nursing
interventions, and coordinating the patient’s activities
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The Patient’s Bill of Rights offers patients guidance and protection by stating the
responsibilities of the hospital and its staff toward patients and their families during
hospitalization
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To minimize omission and distortion of facts, the nurse should record information as soon
as it’s gathered
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When assessing a patient’s health history, the nurse should record the current illness
chronologically, beginning with the onset of the problem and continuing to the present
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When assessing a patient’s health history, the nurse should record the current illness
chronologically, beginning with the onset of the problem and continuing to the present
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A nurse shouldn’t give false assurance to a patient
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After receiving preoperative medication, a patient isn’t competent to sign an informed
consent form
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When lifting a patient, a nurse uses the weight of her body instead of the strength in her
arms
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A nurse may clarify a physician’s explanation about an operation or a procedure to a
patient, but must refer questions about informed consent to the physician
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When obtaining a health history from an acutely ill or agitated patient, the nurse should
limit questions to those that provide necessary information
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Eupnea is normal respiration
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If a chest drainage system line is broken or interrupted, the nurse should clamp the tube
immediately
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The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has
a pulse that may be confused with the patient’s pulse
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An inspiration and an expiration count as one respiration
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During blood pressure measurement, the patient should rest the arm against a surface
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It occurs
in ventricular enlargement because the stroke volume varies with each heartbeat
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The upper respiratory tract warms and humidifies inspired air and plays a role in taste,
smell, and mastication
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Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction,
and scalene and sternocleidomastoid muscle use during respiration
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When patients use axillary crutches, their palms should bear the brunt of the weight
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Activities of daily living include eating, bathing, dressing, grooming, toileting, and
interacting socially
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Normal gait has two phases: the stance phase, in which the patient’s foot rests on the
ground, and the swing phase, in which the patient’s foot moves forward
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The phases of mitosis are prophase, metaphase, anaphase, and telophase
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The nurse should follow standard precautions in the routine care of all patients
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The nurse should use the bell of the stethoscope to listen for venous hums and cardiac
murmurs
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The nurse can assess a patient’s general knowledge by asking questions such as “Who is
the president of the United States?”
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During cold application, the pack is applied for 20 minutes and then removed for 10 to 15
minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury
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Bruits commonly indicate life- or limb-threatening vascular disease
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The pons is located above the medulla and consists of white matter (sensory and motor
tracts) and gray matter (reflex centers)
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The autonomic nervous system controls the smooth muscles
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A correctly written patient goal expresses the desired patient behavior, criteria for
measurement, time frame for achievement, and conditions under which the behavior will
occur
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A secondary disability is caused
by inactivity
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The optic disk is yellowish pink and circular, with a distinct border
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Nurses are commonly held liable for failing to keep an accurate count of sponges and
other devices during surgery
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The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and wholegrain cereals
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Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables,
eggs, and whole grains, commonly have a low water content
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Collaboration is joint communication and decision making between nurses and
physicians
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The nurse should never destroy or attempt to obliterate
documentation or leave vacant lines
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Factors that affect body temperature include time of day, age, physical activity, phase
of menstrual cycle, and pregnancy
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The most accessible and commonly used artery for measuring a patient’s pulse rate is the
radial artery
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The rate is slightly faster
in women than in men and much faster in children than in adults
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Laboratory test results are an objective form of assessment data
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The measurement systems most commonly used in clinical practice are the metric system,
apothecaries’ system, and household system
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Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues
against the hand and feeling their rebound
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A patient must sign a separate informed consent form for each procedure
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Before signing an informed consent form, the patient should know whether other
treatment options are available and should understand what will occur during the preoperative,
intraoperative, and postoperative phases; the risks involved; and the possible complications
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In
addition, he should have an opportunity to ask questions
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During percussion, the nurse uses quick, sharp tapping of the fingers or hands against
body surfaces to produce sounds
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It’s used to treat poisoning or drug overdose
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During the evaluation step of the nursing process, the nurse assesses the patient’s
response to therapy
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O
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means each eye
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D
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S
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Therefore, the nurse
must be familiar with the laws of the state in which she works
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Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter
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An adult normally has 32 permanent teeth
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Unlike false labor, true labor produces regular rhythmic contractions, abdominal discomfort,
progressive descent of the fetus, bloody show, and progressive effacement and dilation of
the cervix
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To help a mother break the suction of her breast-feeding infant, the nurse should teach her
to insert a finger at the corner of the infant’s mouth
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Administering high levels of oxygen to a premature neonate can cause blindness as a result
of retrolental fibroplasia
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Amniotomy is artificial rupture of the amniotic membranes
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During pregnancy, weight gain averages 25 to 30 lb (11 to 13
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It produces
abnormalities in up to 40% of cases without interrupting the pregnancy
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Immunity to rubella can be measured by a hemagglutination inhibition test (rubella titer)
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In a woman, a titer greater than 1:8 indicates immunity
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When used to describe the degree of fetal descent during labor, floating means the
presenting part isn’t engaged in the pelvic inlet, but is freely movable (ballotable) above the
pelvic inlet
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When used to describe the degree of fetal descent, engagement means when the largest
diameter of the presenting part has passed through the pelvic inlet
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Fetal station indicates the location of the presenting part in relation to the ischial spine
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Normally, the neonate abducts and extends all
extremities bilaterally and symmetrically, forms a C shape with the thumb and forefinger, and
first adducts and then flexes the extremities
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Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure of 30/15
mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions at least 6 hours
apart accompanied by edema and albuminuria after 20 weeks’ gestation
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Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and fetal
movement felt by the examiner (not usually present until 4 months’ gestation
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If natural light is unavailable, the nurse should examine the infant under a white
light
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The three phases of a uterine contraction are increment, acme, and decrement
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The intensity of a labor contraction can be assessed by the indentability of the uterine wall
at the contraction’s peak
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Other types include platypelloid (flat),
anthropoid (apelike), and android (malelike)
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Pregnant women should be advised that there is no safe level of alcohol intake
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The frequency of uterine contractions, which is measured in minutes, is the time from the
beginning of one contraction to the beginning of the next
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Vitamin K is administered to neonates to prevent hemorrhagic disorders because a
neonate’s intestine can’t synthesize vitamin K
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Before internal fetal monitoring can be performed, a pregnant patient’s cervix must be
dilated at least 2 cm, the amniotic membranes must be ruptured, and the fetus’s presenting
part (scalp or buttocks) must be at station –1 or lower, so that a small electrode can be
attached
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Fetal alcohol syndrome presents in the first 24 hours after birth and produces lethargy,
seizures, poor sucking reflex, abdominal distention, and respiratory difficulty
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Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to 160
beats/minute
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(Remember back to sleep
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The male sperm contributes an X or a Y chromosome; the female ovum contributes an X
chromosome
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The percentage of water in a neonate’s body is about 78% to 80%
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Fertilization produces a total of 46 chromosomes, including an XY combination (male) or an
XX combination (female)
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To perform nasotracheal suctioning in an infant, the nurse positions the infant with his neck
slightly hyperextended in a “sniffing” position, with his chin up and his head tilted back
slightly
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Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of
gestation
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After birth, the neonate’s umbilical cord is tied 1″ (2
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A fetus is considered viable at 20 weeks’ gestation
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Preterm
neonates have heel creases that cover less than two-thirds of the feet
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The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is
delivered
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Therefore, the second breast should be used first at the next feeding
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A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at birth
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A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less at birth
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When teaching parents to provide umbilical cord care, the nurse should teach them to
clean the umbilical area with a cotton ball saturated with alcohol after every diaper change
to prevent infection and promote drying
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Teenage mothers are more likely to have low-birth-weight neonates because they seek
prenatal care late in pregnancy (as a result of denial) and are more likely than older mothers
to have nutritional deficiencies
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Linea nigra, a dark line that extends from the umbilicus to the mons pubis, commonly
appears during pregnancy and disappears after pregnancy
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Implantation in the uterus occurs 6 to 10 days after ovum fertilization
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Placenta previa is abnormally low implantation of the placenta so that it encroaches on or
covers the cervical os
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In complete (total) placenta previa, the placenta completely covers the cervical os
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In partial (incomplete or marginal) placenta previa, the placenta covers only a portion of
the cervical os
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Abruptio placentae is premature separation of a normally implanted placenta
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It’s a transient vasomotor
response that occurs primarily in the arms and legs of infants who are exposed to cold
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The classic triad of symptoms of preeclampsia are hypertension, edema, and proteinuria
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She also should use an
additional birth control method for 1 week
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Eclampsia is the occurrence of seizures that aren’t caused by a cerebral disorder in a patient
who has pregnancy-induced hypertension
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In placenta previa, bleeding is painless and seldom fatal on the first occasion, but it becomes
heavier with each subsequent episode
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Treatment for abruptio placentae is usually immediate cesarean delivery
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Drugs used to treat withdrawal symptoms in neonates include phenobarbital (Luminal),
camphorated opium tincture (paregoric), and diazepam (Valium)
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The narrowest diameter of the pelvic inlet is the anteroposterior (diagonal conjugate)
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Infants with Down syndrome typically have marked hypotonia, floppiness, slanted eyes,
excess skin on the back of the neck, flattened bridge of the nose, flat facial features,
spadelike hands, short and broad feet, small male genitalia, absence of Moro’s reflex, and
a simian crease on the hands
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The failure rate of a contraceptive is determined by the experience of 100 women for 1 year
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003 to 1
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A lower specific gravity suggests
overhydration; a higher one suggests dehydration
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The neonatal period extends from birth to day 28
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She should let the breasts airdry to prevent them from cracking
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Breast-feeding mothers should increase their fluid intake to 2½ to 3 qt (2,500 to 3,000 ml)
daily
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After feeding an infant with a cleft lip or palate, the nurse should rinse the infant’s mouth
with sterile water
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The nurse instills erythromycin in a neonate’s eyes primarily to prevent blindness caused
by gonorrhea or chlamydia
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Human immunodeficiency virus (HIV) has been cultured in breast milk and can be
transmitted by an HIV-positive mother who breast-feeds her infant
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A fever in the first 24 hours postpartum is most likely caused by dehydration rather than
infection
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Preterm neonates or neonates who can’t maintain a skin temperature of at least 97
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4° C) should receive care in an incubator (Isolette) or a radiant warmer
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It occurs 7 to 10 days after childbirth
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Colostrum, the precursor of milk, is the first secretion from the breasts after delivery
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The length of the uterus increases from 2½” (6
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5
cm from the diagonal conjugate (usually 12 cm)
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5 cm enables the
fetal head (usually 10 cm) to pass
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The smallest outlet measurement of the pelvis is the intertuberous diameter, which is the
transverse diameter between the ischial tuberosities
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Electronic fetal monitoring is used to assess fetal well-being during labor
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The time may
vary from 5 to 20 minutes
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Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of
amniotic fluid
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A pregnant patient normally gains 2 to 5 lb (1 to 2
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5 kg) per week during the last two trimesters
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Neonatal jaundice in the first 24 hours after birth is known as pathological jaundice and
is a sign of erythroblastosis fetalis
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A classic difference between abruptio placentae and placenta previa is the degree of
pain
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2 mg of methylergonovine
(Methergine) is injected I
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over 1 minute while the patient’s blood pressure and uterine
contractions are monitored
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Braxton Hicks contractions are usually felt in the abdomen and don’t cause cervical
change
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The nurse should notify the physician
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Then it begins to
disappear from the face, trunk, arms, and legs, in that order
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In a neonate, hypoglycemia causes temperature instability, hypotonia, jitteriness, and
seizures
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After a stillbirth, the mother should be allowed to hold the neonate to help her come to
terms with the death
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Molding is the process by which the fetal head changes shape to facilitate movement
through the birth canal
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If a woman receives a spinal block before delivery, the nurse should monitor the patient’s
blood pressure closely
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If a woman suddenly becomes hypotensive during labor, the nurse should increase the
infusion rate of I
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fluids as prescribed
...
The best technique for assessing jaundice in a neonate is to blanch the tip of the nose or
the area just above the umbilicus
...
During fetal heart monitoring, early deceleration is caused by compression of the head
during labor
...
After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the patient’s I
...

solution, as prescribed, to promote postpartum involution of the uterus and stimulate
lactation
...
Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or hair
...

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The suturing is typically removed
by 35
weeks’
gestation
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She may have abdominal rigidity; rapid, shallow
respirations; tachycardia; and shock
...
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower
abdomen, with spotting and cramping
...

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If radiography is essential, it should be performed only after 36 weeks’
gestation
...
A pregnant patient who has had rupture of the membranes or who is experiencing
vaginal bleeding shouldn’t engage in sexual intercourse
...
Milia may occur as pinpoint spots over a neonate’s nose
...
The duration of a contraction is timed from the moment that the uterine muscle begins
to tense to the moment that it reaches full relaxation
...

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8° C), foul-smelling vaginal discharge, severe uterine
cramping, nausea, or vomiting
...
When informed that a patient’s amniotic membrane has broken, the nurse should check
fetal heart tones and then maternal vital signs
...
The duration of pregnancy averages 280 days, 40 weeks, 9 calendar months, or 10 lunar
months
...
The initial weight loss for a healthy neonate is 5% to 10% of birth weight
...
The normal hemoglobin value in neonates is 17 to 20 g/dl
...
Crowning is the appearance of the fetus’s head when its largest diameter is encircled by
the vulvovaginal ring
...
A multipara is a woman who has had two or more pregnancies that progressed to
viability, regardless of whether the offspring were alive at birth
...
In a pregnant patient, preeclampsia may progress to eclampsia, which is characterized
by seizures and may lead to coma
...
The Apgar score is used to assess the neonate’s vital functions
...
The score is based on respiratory effort, heart rate, muscle tone,
reflex irritability, and color
...
Because of the anti-insulin effects of placental hormones, insulin requirements increase
during the third trimester
...
Gestational age can be estimated by ultrasound measurement of maternal abdominal
circumference, fetal femur length, and fetal head size
...

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The incidence of congenital
malformation is three times higher in these infants than in those born to nondiabetic women
...
Skeletal system abnormalities and ventricular septal defects are the most common
disorders of infants who are born to diabetic women
...

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These
exercises help strengthen pelvic muscles and improve urine control in postpartum patients
...
Symptoms of postpartum depression range from mild postpartum blues to intense,
suicidal, depressive psychosis
...
The preterm neonate may require gavage feedings because of a weak sucking reflex,
uncoordinated sucking, or respiratory distress
...
Acrocyanosis (blueness and coolness of the arms and legs) is normal in neonates
because of their immature peripheral circulatory system
...
To prevent ophthalmia neonatorum (a severe eye infection caused by maternal
gonorrhea), the nurse may administer one of three drugs, as prescribed, in the neonate’s
eyes: tetracycline, silver nitrate, or erythromycin
...
Neonatal testing for phenylketonuria is mandatory in most states
...
The nurse should place the neonate in a 30-degree Trendelenburg position to facilitate
mucus drainage
...
The nurse may suction the neonate’s nose and mouth as needed with a bulb syringe or
suction trap
...
To prevent heat loss, the nurse should place the neonate under a radiant warmer during
suctioning and initial delivery-room care, and then wrap the neonate in a warmed blanket
for transport to the nursery
...
The umbilical cord normally has two arteries and one vein
...
When providing care, the nurse should expose only one part of an infant’s body at a time
...
Lightening is settling of the fetal head into the brim of the pelvis
...
If the neonate is stable, the mother should be allowed to breast-feed within the neonate’s
first hour of life
...
The nurse should check the neonate’s temperature every 1 to 2 hours until it’s maintained
within normal limits
...
At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg), measures 18″ to 22″ (45
...
5 cm), and has a chest
circumference that’s 1″ (2
...

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7° to 37
...

239
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The triangular posterior fontanel usually closes by age 2 months
...
In the neonate, a straight spine is normal
...

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242
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They usually appear along a
line that runs from each axilla, through the normal nipple area, and to the groin
...
Meconium is a material that collects in the fetus’s intestines and forms the neonate’s first
feces, which are black and tarry
...
The presence of meconium in the amniotic fluid during labor indicates possible fetal
distress and the need to evaluate the neonate for meconium aspiration
...
To assess a neonate’s rooting reflex, the nurse touches a finger to the cheek or the corner
of the mouth
...

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Their color depends on how close
melanocytes are to the surface of the skin
...

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249
...

It may be rubbed into the neonate’s skin or washed away in one or two baths
...
Caput succedaneum is edema that develops in and under the fetal scalp during labor
and delivery
...
The edema
doesn’t cross the suture line
...
Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red lesion on a
neonate’s face or neck
...
The Guthrie test (a screening test for phenylketonuria) is most reliable if it’s done between
the second and sixth days after birth and is performed after the neonate has ingested
protein
...
To assess coordination of sucking and swallowing, the nurse should observe the neonate’s
first breast-feeding or sterile water bottle-feeding
...
To establish a milk supply pattern, the mother should breast-feed her infant at least every
4 hours
...

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By
compressing and displacing the lungs and heart, this disorder can cause respiratory distress
shortly after birth
...
Common complications of early pregnancy (up to 20 weeks’ gestation) include fetal loss
and serious threats to maternal health
...
Fetal embodiment is a maternal developmental task that occurs in the second trimester
...

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264
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The increased volume consists of plasma and causes an imbalance between
the ratio of red blood cells to plasma and a resultant decrease in hematocrit
...
Mean arterial pressure of greater than 100 mm Hg after 20 weeks of pregnancy is
considered hypertension
...
The treatment for supine hypotension syndrome (a condition that sometimes occurs in
pregnancy) is to have the patient lie on her left side
...
A contributing factor in dependent edema in the pregnant patient is the increase of
femoral venous pressure from 10 mm Hg (normal) to 18 mm Hg (high)
...
Hyperpigmentation of the pregnant patient’s face, formerly called chloasma and now
referred to as melasma, fades after delivery
...
The hormone relaxin, which is secreted first by the corpus luteum and later by the
placenta, relaxes the connective tissue and cartilage of the symphysis pubis and the
sacroiliac joint to facilitate passage of the fetus during delivery
...
Ladin’s sign, an early indication of pregnancy, causes softening of a spot on the anterior
portion of the uterus, just above the uterocervical juncture
...
Progesterone maintains the integrity of the pregnancy by inhibiting uterine motility
...
During pregnancy, the abdominal line from the symphysis pubis to the umbilicus changes
from linea alba to linea nigra
...
In neonates, cold stress affects the circulatory, regulatory, and respiratory systems
...
Obstetric data can be described by using the F/TPAL system:
F/T:
Full-term
delivery
at
38
weeks
or
longer
P: Preterm
delivery
between
20
and 37
weeks
A: Abortion
or
loss
of
fetus before
20
weeks L: Number of
children living (if a child has died, further explanation is needed to clarify the discrepancy in
numbers)
...
Parity doesn’t refer to the number of infants delivered, only the number of deliveries
...
Women who are carrying more than one fetus should be encouraged to gain 35 to 45 lb
(15
...
5 kg) during pregnancy
...
The recommended amount of iron supplement for the pregnant patient is 30 to 60 mg
daily
...
Drinking six alcoholic beverages a day or a single episode of binge drinking in the first
trimester
can cause fetal alcohol
syndrome
...

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280
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During this
phase, the uterus and placenta fill with blood and allow for the exchange of oxygen, carbon
dioxide, and nutrients
...
In a patient who has hypertonic contractions, the uterus doesn’t have an opportunity to
relax and there is no interval between contractions
...

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288
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290
...
5 cm)
away
...
In a neonate, low-set ears are associated with chromosomal abnormalities such as Down
syndrome
...
Meconium is usually passed in the first 24 hours; however, passage may take up to 72
hours
...
Boys who are born with hypospadias shouldn’t be circumcised at birth because the
foreskin may be needed for constructive surgery
...
In the neonate, the normal blood glucose level is 45 to 90 mg/dl
...
Hepatitis B vaccine is usually given within 48 hours of birth
...
Hepatitis B immune globulin is usually given within 12 hours of birth
...
HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is an unusual
variation of pregnancy-induced hypertension
...
Maternal serum alpha-fetoprotein is detectable at 7 weeks of gestation and peaks in the
third trimester
...
Low levels are associated with Down syndrome
...
An arrest of descent occurs when the fetus doesn’t descend through the pelvic cavity
during labor
...

300
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301
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302
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303
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304
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305
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306
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307
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308
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309
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310
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321
...

322
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323
...

324
...

325
...

326
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327
...

328
...
The vaccine can be
administered after delivery, but the patient should be instructed to avoid becoming
pregnant for 3 months
...
A 16-year-old girl who is pregnant is at risk for having a low-birth-weight neonate
...
The mother’s Rh factor should be determined before an amniocentesis is performed
...
Maternal hypotension is a complication of spinal block
...
After delivery, if the fundus is boggy and deviated to the right side, the patient should
empty her bladder
...
Before providing a specimen for a sperm count, the patient should avoid ejaculation for
48 to 72 hours
...
The hormone human chorionic gonadotropin is a marker for pregnancy
...
Painless vaginal bleeding during the last trimester of pregnancy may indicate placenta
previa
...
During the transition phase of labor, the woman usually is irritable and restless
...
Because women with diabetes have a higher incidence of birth anomalies than women
without diabetes, an alpha-fetoprotein level may be ordered at 15 to 17 weeks’ gestation
...
To avoid puncturing the placenta, a vaginal examination shouldn’t be performed on a
pregnant patient who is bleeding
...
A patient who has postpartum hemorrhage caused by uterine atony should be given
oxytocin as prescribed
...
Laceration of the vagina, cervix, or perineum produces bright red bleeding that often
comes in spurts
...

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1
...

2
...
To turn the client after lumbar Laminectomy, use logrolling technique
4
...

5
...

6
...
He is placed in Bryant’s traction
...
angle is his weight isn’t adequate to provide sufficient
countertraction, so his entire body must be used
...
Swing-through crutch gait is done by advancing both crutches together & the client moves
both legs past the level of the crutches
...
The appropriate nursing measure to prevent displacement of the prosthesis after a right total
hip replacement for arthritis is to place the patient in the position of right leg abducted
...
Pain on non-use of joints, subcutaneous nodules & elevated ESR are characteristic
manifestations of rheumatoid arthritis
...
Teaching program of a patient w/ SLE should include emphasis on walking in shaded area
...
Otosclerosis is characterized by replacement of normal bones by spongy & highly
vascularized bones
...
Use of high pitched voice is inappropriate for the client w/ hearing impairment
...
Rinne’s test compares air conduction w/ bone conduction
...
Vertigo is the most characteristic manifestation of Meniere’s disease
...
Low sodium is the diet for a client w/ Meniere’s disease
...
A client who had cataract surgery should be told to call his MD if he has eye pain
...
Risk for Injury takes priority for a client w/ Meniere’s disease
...
Irrigate the eye w/ sterile saline is the priority nursing intervention when the client has a foreign
body protruding from the eye
...
Snellen’s Test assesses visual acuity
...
Presbyopia is an eye disorder characterized by lessening of the effective powers of
accommodation
...
The primary problem in cataract is blurring of vision
...
The primary reason for performing iridectomy after cataract extraction is to prevent
secondary glaucoma
...
In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement
of the iris
...
Glaucoma is characterized by irreversible blindness
...
Hyperopia is corrected by convex lens
...
Pterygium is caused primarily by exposure to dust
...
A sterile chronic granulomatous inflammation of the meibomian gland is chalazion
...
The surgical procedure w/c involves removal of the eyeball is enucleation
...
Snellen’s Test assesses visual acuity
...
Presbyopia is an eye disorder characterized by lessening of the effective powers of
accommodation
...
The primary problem in cataract is blurring of vision
...
The primary reason for performing iridectomy after cataract extraction is to prevent
secondary glaucoma
...
In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement
of the iris
...
Glaucoma is characterized by irreversible blindness
...
Hyperopia is corrected by convex lens
...
Pterygium is caused primarily by exposure to dust
...
A sterile chronic granulomatous inflammation of the meibomian gland is chalazion
...
The surgical procedure w/c involves removal of the eyeball is enucleation
...
The client is for EEG this morning
...

39
...
The nursing diagnosis that would have the highest priority in the care of the client who has
become comatose following cerebral hemorrhage is Ineffective Airway Clearance
...
The initial nursing action—for a client who is in the clonic phase of a tonic-clonic seizure— is
to obtain equipment for orotracheal suctioning
...
The first nursing intervention in a quadriplegic client who is experiencing autonomic
dysreflexia is to elevate his head as high as possible
...
Following surgery for a brain tumor near the hypothalamus, the nursing assessment should
include observing for inability to regulate body temp
...
Post-myelogram (using metrizamide (Amipaque) care includes keeping head elevated for
at least 8 hrs
...
Homonymous hemianopsia is described by a client had CVA & can only see the nasal visual
field on one side & the temporal portion on the opposite side
...
Ticlopidine may be prescribed to prevent thromboembolic CVA
...
To maintain airway patency during a stroke in evolution, have orotracheal suction available
at all times
...
For a client w/ CVA, the gag reflex must return before the client is fed
...
Clear fluids draining from the nose of a client who had a head trauma 3 hrs ago may indicate
basilar skull fracture
...
An adverse effect of gingival hyperplasia may occur during Phenytoin (DIlantin) therapy
...
Urine output increased: best shows that the mannitol is effective in a client w/ increased ICP
...
A client w/ C6 spinal injury would most likely have the symptom of quadriplegia
...
Falls are the leading cause of injury in elderly people
...
Primary prevention is true prevention
...

55
...
Examples include purified protein derivative (PPD),
breast self-examination, testicular self-examination, and chest X-ray
...
Tertiary prevention is treatment to prevent long-term complications
...
A patient indicates that he’s coming to terms with having a chronic disease when he says,
“I’m never going to get any better
...
On noticing religious artifacts and literature on a patient’s night stand, a culturally aware
nurse would ask the patient the meaning of the items
...
The nitrogen balance estimates the difference between the intake and use of protein
...
A Mexican patient may request the intervention of a curandero, or faith healer, who involves
the family in healing the patient
...
In an infant, the normal hemoglobin value is 12 g/dl
...
Most of the absorption of water occurs in the large intestine
...
Most nutrients are absorbed in the small intestine
...
When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the
last 24 hours?”
65
...

66
...

67
...

68
...

69
...

70
...
5 kg) in 1 week, the patient must decrease his weeklyv intake by 3,500 calories
(approximately 500 calories daily)
...

71
...

72
...

73
...

74
...

75
...

76
...

77
...

78
...

79
...

80
...

81
...

82
...

83
...

84
...

85
...

86
...

87
...

88
...

89
...

90
...

91
...


92
...
A Hindu patient is likely to request a vegetarian diet
...
Referred pain is pain that’s felt at a site other than its origin
...
Alleviating pain by performing a back massage is consistent with the gate control theory
...
Romberg’s test is a test for balance or gait
...
Pain seems more intense at night because the patient isn’t distracted by daily activities
...
Older patients commonly don’t report pain because of fear of treatment, lifestyle changes,
or dependency
...
No pork or pork products are allowed in a Muslim diet
...
Two goals of Healthy People 2010 are:
100
...
Eliminate health disparities among different segments of the population
...
A community nurse is serving as a patient’s advocate if she tells av malnourished patient
to go to a meal program at a local park
...
If a patient isn’t following his treatment plan, the nurse should first ask why
...
When a patient is ill, it’s essential for the members of his family to maintain communication
about his health needs
...
Ethnocentrism is the universal belief that one’s way of life is superior to others’
...
When a nurse is communicating with a patient through an interpreter,v the nurse should
speak to the patient and the interpreter
...
In accordance with the “hot-cold” system used by some Mexicans,v Puerto Ricans, and
other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described
as “cold
...
Prejudice is a hostile attitude toward individuals of a particular group
...
Discrimination is preferential treatment of individuals of a particular group
...

110
...

111
...

112
...

113
...

114
...

115
...

116
...

117
...
Sites for intradermal injection include the inner arm, the upper chest, and on the back,
under the scapula
...
When evaluating whether an answer on an examination is correct, thev nurse should
consider whether the action that’s described promotes autonomy (independence), safety,
self-esteem, and a sense of belonging
...
Veracity is truth and is an essential component of a therapeutic relationship between a
health care provider and his patient
...
Beneficence is the duty to do no harm and the duty to do good
...
128
...

121
...

A = Airway
...

B = Breathing
...

C = Circulation
...

D = Disease processes
...
For example, if a patient has
terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern
...
This category includes such issues as writing anv incident report and
completing the patient chart
...

122
...

123
...

124
...

125
...

126
...

127
...
Resistive exercises increase muscle mass
...
Isometric exercises are performed on an extremity that’s in a cast
...

A back rub is
an example of the gate-control theory of pain
...
Anything that’s located below the waist is considered unsterile; av sterile field becomes
unsterile when it comes in contact with any unsterile item; a sterile field must be monitored
continuously; and a border of 1″ (2
...

130
...

131
...


132
...

133
...

134
...

135
...

136
...

137
...

138
...

139
...

140
...

141
...

142
...

143
...

144
...

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1
...

2
...

3
...

4
...

5
...

6
...

7
...

8
...

9
...

10
...

11
...

12
...

13
...

14
...
Therefore, offer analgesics if pain
is suspected or administer the medication if the client asks for it
...
Signs that a child with cystic fibrosis is responding to pancreatic enzymes are the absence of
steatorrhea, improved appetite, and absence of abdominal pain
...
Roseola appears as discrete rose-pink macules that first appear on the trunk and that fade
when pressure is applied
...
A ninety degree-ninety degree traction is used for fracture of a child’s femur or tibia
...
One sign of developmental dysplasia is limping during ambulation
...
Circumcision wouldn’t be performed on a male child with hypospadias because the foreskin
may be needed during surgical reconstruction
...
Neonatal abstinence syndrome is manifested in central nervous system hyperirritability (for
example, hyperactive Moro reflex) and gastrointestinal symptoms (watery stools)
...
Classic signs of shaken baby syndrome are seizures, slow apical pulse difficulty breathing,
and retinal hemorrhage
...
An infant born to an HIV-positive mother will usually receive AZT (zidovudine) for the first 6
weeks of life
...
Infants born to an HIV-positive mother should receive all immunizations of schedule
...
Blood pressure in the arms and legs is essentially the same in infants
...
A newborn typically wets 6 to 10 diapers per day
...
When bottle-feeding a newborn with a cleft palate, hold the infant’s head in an upright
position
...
Because of circulating maternal antibodies that will decrease the immune response, the
measles, mumps, and rubella (MMR) vaccine shouldn’t be given until the infant has reached
1 year of age
...
Before feeding an infant any fluid that has been warmed, test a drop of the liquid on your
own skin to prevent burning the infant
...
Although microwaving food and fluids isn’t recommend for infants, it’s commonplace in the
United States
...

30
...

31
...

32
...

33
...

34
...
Kohlberg’s stages of moral development; Erikson’s eight stages of development; and
Piaget’s phases of cognitive development
...
The primary concern with infusing large volumes of fluid is circulatory overload
...

37
...
For infants, more falls, burns, and suffocation occur; for toddlers, there are more burns,
poisoning, and drowning for preschoolers, more playground equipment accidents, choking,
poisoning, and drowning; and for adolescents, more automobile accidents, drowning, fires,
and firearm accidents
...
A child in Bryant’s traction who’s younger than age 3 or weighs less than 30 lb (13
...
The knees should be slightly flexed,
and the legs should be extended at a right angle to the body
...
The body provides the traction mechanism
...
In an infant, a bulging fontanel is the most significant sign of increasing intracranial pressure
...
According to Kübler-Ross, the five stages of death and dying are denial, anger, bargaining,
depression, and acceptance
...
Flight of ideas is an alteration in thought processes that’s characterized by skipping from one
topic to another, unrelated topic
...
La belle indifférence is the lack of concern for a profound disability, such as blindness or
paralysis that may occur in a patient who has a conversion disorder
...
Moderate anxiety decreases a person’s ability to perceive and concentrate
...

5
...

6
...

7
...

A normal laboratory value is 0
...
5 mEq/L
...
Early signs and symptoms of alcohol withdrawal include anxiety, anorexia, tremors, and
insomnia
...

9
...

10
...

11
...

12
...

13
...

14
...

15
...

16
...

17
...
It continually evaluates thoughts and actions, rewarding the
good and punishing the bad
...
)
18
...
(Remember i for instinctual and d for drive
...
Denial is the defense mechanism used by a patient who denies the reality of an event
...
Tyramine-rich food, such as aged cheese, chicken liver, avocados, bananas, meat
tenderizer, salami, bologna, Chianti wine, and beer may cause severe hypertension in a
patient who takes a monoamine oxidase inhibitor
...
Memory disturbance is a classic sign of Alzheimer’s disease
...
In a psychiatric setting, seclusion is used to reduce overwhelming environmental stimulation,
protect the patient from self-injury or injury to others, and prevent damage to hospital
property
...
Seclusion
controls external behavior until the patient can assume self-control and helps the patient to
regain self-control
...
A patient who takes a monoamine oxidase inhibitor should be weighed biweekly and
monitored for suicidal tendencies
...
If the patient who takes a monoamine oxidase inhibitor has palpitations, headaches, or
severe orthostatic hypotension, the nurse should withhold the drug and notify the physician
...
Common causes of child abuse are poor impulse control by the parents and the lack of
knowledge of growth and development
...
The diagnosis of Alzheimer’s disease is based on clinical findings of two or more cognitive
deficits, progressive worsening of memory, and the results of a neuropsychological test
...
Thought blocking is loss of the train of thought because of a defect in mental processing
...
A compulsion is an irresistible urge to perform an irrational act, such as walking in a clockwise
circle before leaving a room or washing the hands repeatedly
...
A patient who has a chosen method and a plan to commit suicide in the next 48 to 72 hours
is at high risk for suicide
...
The therapeutic serum level for lithium is 0
...
5 mEq/L
...
Phobic disorders are treated with desensitization therapy, which gradually exposes a patient
to an anxiety-producing stimulus
...
Dysfunctional grieving is absent or prolonged grief
...
During phase I of the nurse-patient relationship (beginning, or orientation, phase), the nurse
obtains an initial history and the nurse and the patient agree to a contract
...
During phase II of the nurse-patient relationship (middle, or working, phase), the patient
discusses his problems, behavioral changes occur, and self-defeating behavior is resolved or
reduced
...
During phase III of the nurse-patient relationship (termination, or resolution, phase), the nurse
terminates the therapeutic relationship and gives the patient positive feedback on his
accomplishments
...
According to Freud, a person between ages 12 and 20 is in the genital stage, during which
he learns independence, has an increased interest in members of the opposite sex, and
establishes an identity
...
According to Erikson, the identity-versus-role confusion stage occurs between ages 12 and
20
...
Tolerance is the need for increasing amounts of a substance to achieve an effect that
formerly was achieved with lesser amounts
...
Suicide is the third leading cause of death among white teenagers
...
Most teenagers who kill themselves made a previous suicide attempt and left telltale signs
of their plans
...
In Erikson’s stage of generativity versus despair, generativity (investment of the self in the
interest of the larger community) is expressed through procreation, work, community service,
and creative endeavors
...
Alcoholics Anonymous recommends a 12-step program to achieve sobriety
...
Signs and symptoms of anorexia nervosa include amenorrhea, excessive weight loss, lanugo
(fine body hair), abdominal distention, and electrolyte disturbances
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A serum lithium level that exceeds 2
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(Schizophrenic patients think in concrete terms and might interpret
the glass house proverb as “If you throw a stone in a glass house, the house will break
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Signs of lithium toxicity include diarrhea, tremors, nausea, muscle weakness, ataxia, and
confusion
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A labile affect is characterized by rapid shifts of emotions and mood
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Amnesia is loss of memory from an organic or inorganic cause
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A person who has borderline personality disorder is demanding and judgmental in
interpersonal relationships and will attempt to split staff by pointing to discrepancies in the
treatment plan
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Disulfiram (Antabuse) shouldn’t be taken concurrently with metronidazole (Flagyl) because
they may interact and cause a psychotic reaction
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In rare cases, electroconvulsive therapy causes arrhythmias and death
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A patient who is scheduled for electroconvulsive therapy should receive nothing by mouth
after midnight to prevent aspiration while under anesthesia
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Electroconvulsive therapy is normally used for patients who have severe depression that
doesn’t respond to drug therapy
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For electroconvulsive therapy to be effective, the patient usually receives 6 to 12 treatments
at a rate of 2 to 3 per week
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During the manic phase of bipolar affective disorder, nursing care is directed at slowing the
patient down because the patient may die as a result of self-induced exhaustion or injury
...
For a patient with Alzheimer’s disease, the nursing care plan should focus on safety measures
...
After sexual assault, the patient’s needs are the primary concern, followed by medicolegal
considerations
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Patients who are in a maintenance program for narcotic abstinence syndrome receive 10
to 40 mg of methadone (Dolophine) in a single daily dose and are monitored to ensure that
the drug is ingested
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Stress management is a short-range goal of psychotherapy
...
The mood most often experienced by a patient with organic brain syndrome is irritability
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Creative intuition is controlled by the right side of the brain
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Methohexital (Brevital) is the general anesthetic that’s administered to patients who are
scheduled for electroconvulsive therapy
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The decision to use restraints should be based on the patient’s safety needs
...
Diphenhydramine (Benadryl) relieves the extrapyramidal adverse effects of psychotropic
drugs
...
In a patient who is stabilized on lithium (Eskalith) therapy, blood lithium levels should be
checked 8 to 12 hours after the first dose, then two or three times weekly during the first
month
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This loss of function is involuntary, but diagnostic tests show no organic cause
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Chlordiazepoxide (Librium) is the drug of choice for treating alcohol withdrawal
symptoms
...
For a patient who is at risk for alcohol withdrawal, the nurse should assess the pulse rate
and blood pressure every 2 hours for the first 12 hours, every 4 hours for the next 24 hours, and
every 6 hours thereafter (unless the patient’s condition becomes unstable)
...
Alcohol detoxification is most successful when carried out in a structured environment by
a supportive, nonjudgmental staff
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The nurse should follow these guidelines when caring for a patient who is experiencing
alcohol withdrawal: Maintain a calm environment, keep intrusions to a minimum, speak
slowly and calmly, adjust lighting to prevent shadows and glare, call the patient by name,
and have a friend or family member stay with the patient, if possible
...
The therapeutic regimen for an alcoholic patient includes folic acid, thiamine, and
multivitamin supplements as well as adequate food and fluids
...
A patient who is addicted to opiates (drugs derived from poppy seeds, such as heroin
and morphine) typically experiences withdrawal symptoms within 12 hours after the last
dose
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Its major
objective is to reestablish rational communication between family members
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When caring for a patient who is hostile or angry, the nurse should attempt to remain
calm, listen impartially, use short sentences, and speak in a firm, quiet voice
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Ritualism and negativism are typical toddler behaviors
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It’s
marked by hallucinations, confabulation, amnesia, and disturbances of orientation
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A patient with antisocial personality disorder often engages in confrontations with
authority figures, such as police, parents, and school officials
...
A patient with paranoid personality disorder exhibits suspicion, hypervigilance, and
hostility toward others
...
Depression is the most common psychiatric disorder
...
Adverse reactions to tricyclic antidepressant drugs include tachycardia, orthostatic
hypotension, hypomania, lowered seizure threshold, tremors, weight gain, problems with
erections or orgasms, and anxiety
...
The Minnesota Multiphasic Personality Inventory consists of 550 statements for the subject
to interpret
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Patients have inappropriate
affect, transient paranoia, disorientation to time, memory loss, careless dressing, and
impaired judgment
...
The middle stage of Alzheimer’s disease lasts 4 to 7 years and is marked by profound
personality changes, loss of independence, disorientation, confusion, inability to recognize
family members, and nocturnal restlessness
...
The last stage of Alzheimer’s disease occurs during the final year of life and is
characterized by a blank facial expression, seizures, loss of appetite, emaciation, irritability,
and total dependence
...
Threatening a patient with an injection for failing to take an oral drug is an example of
assault
...
Reexamination of life goals is a major developmental task during middle adulthood
...

Acute alcohol withdrawal causes anorexia, insomnia, headache, and restlessness and
escalates to a syndrome that’s characterized by agitation, disorientation, vivid
hallucinations, and tremors of the hands, feet, legs, and tongue
...
In a hospitalized alcoholic, alcohol withdrawal delirium most commonly occurs 3 to 4
days after admission
...
In sensory deprivation, overall sensory input is decreased
...
Confrontation is a communication technique in which the nurse points out discrepancies
between the patient’s words and his nonverbal behaviors
...
For a patient with substance-induced delirium, the time of drug ingestion can help to
determine whether the drug can be evacuated from the body
...
Treatment for alcohol withdrawal may include administration of I
...
glucose for
hypoglycemia, I
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fluid containing thiamine and other B vitamins, and antianxiety,
antidiarrheal, anticonvulsant, and antiemetic drugs
...
The alcoholic patient receives thiamine to help prevent peripheral neuropathy and
Korsakoff’s syndrome
...
Alcohol withdrawal may precipitate seizure activity because alcohol lowers the seizure
threshold in some people
...
Paraphrasing is an active listening technique in which the nurse restates what the patient
has just said
...
A patient with Korsakoff’s syndrome may use confabulation (made up information) to
cover memory lapses or periods of amnesia
...
People with obsessive-compulsive disorder realize that their behavior is unreasonable, but
are powerless to control it
...
When witnessing psychiatric patients who are engaged in a threatening confrontation,
the nurse should first separate the two individuals
...
Patients with anorexia nervosa or bulimia must be observed during meals and for some
time afterward to ensure that they don’t purge what they have eaten
...
Transsexuals believe that they were born the wrong gender and may seek hormonal or
surgical treatment to change their gender
...
Fugue is a dissociative state in which a person leaves his familiar surroundings, assumes a
new identity, and has amnesia about his previous identity
...
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A patient who is taking lithium shouldn’t restrict his
sodium intake
...
A patient who is taking lithium should stop taking the drug and call his physician if he
experiences vomiting, drowsiness, or muscle weakness
...
The patient who is taking a monoamine oxidase inhibitor for depression can include
cottage cheese, cream cheese, yogurt, and sour cream in his diet
...
Sensory overload is a state in which sensory stimulation exceeds the individual’s capacity
to tolerate or process it
...
Symptoms of sensory overload include a feeling of distress and hyperarousal with
impaired thinking and concentration
...
A sign of sensory deprivation is a decrease in stimulation from the environment or from
within oneself, such as daydreaming, inactivity, sleeping excessively, and reminiscing
...
The three stages of general adaptation syndrome are alarm, resistance, and exhaustion
...
A maladaptive response to stress is drinking alcohol or smoking excessively
...
Hyperalertness and the startle reflex are characteristics of posttraumatic stress disorder
...
A treatment for a phobia is desensitization, a process in which the patient is slowly
exposed to the feared stimuli
...
Symptoms of major depressive disorder include depressed mood, inability to experience
pleasure, sleep disturbance, appetite changes, decreased libido, and feelings of
worthlessness
...
Clinical signs of lithium toxicity are nausea, vomiting, and lethargy
...
Asking too many “why” questions yields scant information and may overwhelm a
psychiatric patient and lead to stress and withdrawal
...
Remote memory may be impaired in the late stages of dementia
...
According to the DSM-IV, bipolar II disorder is characterized by at least one manic
episode that’s accompanied by hypomania
...
The nurse can use silence and active listening to promote interactions with a depressed
patient
...
A psychiatric patient with a substance abuse problem and a major psychiatric disorder
has a dual diagnosis
...
When a patient is readmitted to a mental health unit, the nurse should assess compliance
with medication orders
...
Alcohol potentiates the effects of tricyclic antidepressants
...
Flight of ideas is movement from one topic to another without any discernible
connection
...
Conduct disorder is manifested by extreme behavior, such as hurting people and
animals
...
During the “tension-building” phase of an abusive relationship, the abused individual
feels helpless
...
In the emergency treatment of an alcohol-intoxicated patient, determining the bloodalcohol level is paramount in determining the amount of medication that the patient needs
...
Side effects of the antidepressant fluoxetine (Prozac) include diarrhea, decreased libido,
weight loss, and dry mouth
...
Before electroconvulsive therapy, the patient is given the skeletal muscle relaxant
succinylcholine (Anectine) by I
...
administration
...
When a psychotic patient is admitted to an inpatient facility, the primary concern is
safety, followed by the establishment of trust
...
An effective way to decrease the risk of suicide is to make a suicide contract with the
patient for a specified period of time
...
A depressed patient should be given sufficient portions of his favorite foods, but shouldn’t
be overwhelmed with too much food
...
The nurse should assess the depressed patient for suicidal ideation
...
Delusional thought patterns commonly occur during the manic phase of bipolar disorder
...
Apathy is typically observed in patients who have schizophrenia
...
Manipulative behavior is characteristic of a patient who has passive– aggressive
personality disorder
...
When a patient who has schizophrenia begins to hallucinate, the nurse should redirect
the patient to activities that are focused on the here and now
...
A patient who is receiving lithium (Eskalith) therapy should report diarrhea, vomiting,
drowsiness, muscular weakness, or lack of coordination to the physician immediately
...
The therapeutic serum level of lithium (Eskalith) for maintenance is 0
...
2 mEq/L
...
Obsessive-compulsive disorder is an anxiety-related disorder
...
Al-Anon is a self-help group for families of alcoholics
...
Desensitization is a treatment for phobia, or irrational fear
...
After electroconvulsive therapy, the patient is placed in the lateral position, with the head
turned to one side
...
A delusion is a fixed false belief
...
Giving away personal possessions is a sign of suicidal ideation
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An appropriate response is that he would mail the
envelope
...
After electroconvulsive therapy, the patient should be monitored for post-shock amnesia
...
A mother who continues to perform cardiopulmonary resuscitation after a physician
pronounces a child dead is showing denial
...
Transvestism is a desire to wear clothes usually worn by members of the opposite sex
...
Tardive dyskinesia causes excessive blinking and unusual movement of the tongue, and
involuntary sucking and chewing
...
Trihexyphenidyl (Artane) and benztropine (Cogentin) are administered to counteract
extrapyramidal adverse effects
...
To prevent hypertensive crisis, a patient who is taking a monoamine oxidase inhibitor
should avoid consuming aged cheese, caffeine, beer, yeast, chocolate, liver, processed
foods, and monosodium glutamate
...
Extrapyramidal symptoms include parkinsonism, dystonia, akathisia (“ants in the pants”),
and tardive dyskinesia
...
One theory that supports the use of electroconvulsive therapy suggests that it
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