A profession is generally distinguished from other kinds of occupations/vocations by: 1.

Requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed usually entrusted to higher education. 2. An orientation of the individual toward service, either to a community or to an organization. 3. The members must be united and identified through their membership and they must be clearly separated from the laypeople or the ordinary congregations. 4. The society which it intends to serve has an indispensable need for such services and which others cannot provide and the society accepts it. 5. The techniques or skills applied are the product of scientifically proven and long experience. 6. REQUIREMENT TO EXERCISE DISCRETION AND JUDGMENT as to the time and manner of the performance of the duty. 7. The presence of common values, cultures, and norms uniquely found among its members which are also being guided by its own code of ethics. 8. The ability to continue its research to expand constantly its body of knowledge. Conceptual Framework - group of related concepts. It can also be viewed as an umbrella under which many theories can exist (Cresia & Parker 1991,p7). Theory- is made up of concepts and propositions; however, a theory accounts for phenomena with much greater specificity. Nightangle's Environmental theory - Florence Nightangle, "the mother of modern nursing" espoused her theory focusing on the environment. She linked health with five environmental factors: " " " " " pure or fresh air pure water efficient drainage cleanliness light

Informed Consent -The patient UNDERSTANDS the reason for the proposed intervention, with its benefits and risks, and agrees to the treatment by affixing his signature in the consent form. It generally contains the following elements: " disclosure " understanding " voluntariness " competence " permission giving Practicing Professional Nurse- a person who is engaged in the practice of nursing profession or is performing acts or activities, whether regularly or occasionally, including one who is employed in a

government office or in a private firm, company or corporation whose duties require knowledge and application of the nursing profession (Rule 1 Sect. 3 (f) IRR RA 9173). Private Duty Nurse - is a registered nurse who independently contracts with a patient; a private duty nurse is responsible for the total nursing care of the patient during the period she is with him. all of the three are bill of rights of the patient except option D. a patient must sign a waiver ( HAMA form) if he wants to leave the hospital against medical advice. BASIC HUMAN RIGHTS ON RESEARCH SUBJECTS: " " " " " Right to informed consent Right to refuse and/or withdrawal from participation Right to privacy Right to confidentiality Right to be protected from harm

RA 9173 Philippine Nursing Act of 2002 RATIONALE: When applying a vest restraint, allow room for movement. Never crisscross the flaps in the back; the client may choke himself. Wrapping the vest tightly may impede respirations. Tying a bowknot, rather than a regular knot, secures the straps but allows for quick release.

RATIONALE: The client has a right to know the medication he's getting and its adverse effects. If the physician has explained the medication to the client, it's the nurse's responsibility to reinforce the explanation. A client has the right to refuse medications. Explanation of medications should be done before the client receives them. RATIONALE: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. RATIONALE: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack. RATIONALE: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.

RATIONALE: One cup of low-fat yogurt contains 415 mg of calcium. One cup of skim milk has 302 mg of calcium. One ounce of cheddar cheese has 20 mg of calcium. One cup of ice cream has 176 mg of calcium. RATIONALE: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture. RATIONALE: Restraints should never be applied for staff convenience. The situations described in options A, B, and D could result in client harm; therefore, it's appropriate to apply restraints in these instances. RATIONALE: Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Clients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching. RATIONALE: Narcotics are contraindicated in trauma cases because of the depressive effect on the respiratory center, which can result in hypoxia and increased ICP. All medications would need to be given with caution if there's no medical history. Nothing specifically makes narcotics more contraindicated than other drugs. Narcotics should be used with caution in diabetic clients, but they aren't flatly contraindicated. This situation in itself wouldn't contraindicate narcotics. RATIONALE: After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Extended time out of refrigeration increases the risk of contamination and growth of bacteria. The client could experience fluid overload if the blood is administered too rapidly. RATIONALE: In later years, socialization allows the individual to provide examples of wisdom and courage. Self-realization is achieved during middle life (between ages 46 and 64); during middle life, individuals may also tend to withdraw from mental activity or overcompensate by trying impossible things. Retirement begins in the early later years (between ages 65 and 79). RATIONALE: Linking health and personal behavior is extremely important to disease prevention. By promoting healthy behaviors, individuals are preventing disease and living longer, more productive lives. This issue affects all individuals, not just health maintenance organizations. The external environment is only one of many factors affecting disease processes. RATIONALE: An increased metabolic rate in hyperthyroidism because of excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss face; not gain face; occurs due to the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat

intolerance and widened pulse pressure do occur, but the other answers are incorrect. Clients with hyperthyroidism experience an increase in appetite face; not anorexia. RATIONALE: Physical care is an individual's most basic need according to Maslow's hierarchy of needs. When physiological needs are met and the client feels comfortable, other dimensions of care can be addressed. RATIONALE: The nurse is performing an analysis and formulating a diagnosis by categorizing symptoms or potential health problems. Risk factors could become potential health problems. Evaluation is an integral part of the nursing process and is usually performed as the last phase, referring to the client's outcome and goals and determining if they've been met. Before determining an appropriate nursing diagnosis, a thorough assessment must be done. Implementation is the initiation of the nursing care plan. RATIONALE: The client should be protected from a chill. The water temperature should be 110 to 115 F to compensate for evaporative body cooling during and after the bath. Water that's the same temperature as the body, slightly cooler, or slightly warmer will eventually cool, which could cause discomfort and increase evaporative body cooling. Water that is 115 to 120 F would be too hot and would put the client at risk for burns or discomfort. Water should always be tested with a bath thermometer. RATIONALE: Daily weight shows trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with fluid balance problems. However, if a client is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations. RATIONALE: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and shouldn't be used. RATIONALE: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there's nephrotoxicity, but that situation is uncommon. Gait changes are also uncommon. RATIONALE: Nausea is a common adverse drug effect. Increasing fluid or food intake may alleviate the nausea. Difficulty breathing along with a sensation that the throat is closing up is a type I reaction

(anaphylactic shock). Achy joints and temperature elevation are type II reactions (cytotoxic). An itchy rash with blisters is a type IV reaction (cell-mediated hypersensitivity). RATIONALE: This client may be at risk for altered perceptions related to an unfamiliar environment. Nothing in this case relates to pain or medication for pain. Also, no information is given regarding the client's cognitive function. Impaired sense of time would be included in altered perceptions. RATIONALE: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There's no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals. RATIONALE: To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit. RATIONALE: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that's soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction face; not eversion face; may be a sign of cancer. RATIONALE: Acyclovir reduces symptoms of herpes and also reduces viral shedding and healing time. Doxycycline and tetracycline are used to treat Lyme disease. Penicillin is used to treat syphilis. RATIONALE: Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't a preexisting condition of colorectal cancer. Weight loss face; not gain face; is an indication of colorectal cancer. RATIONALE: Used to visualize the entire colon, colonoscopy aids in the detection of colorectal cancers. Abdominal CT scan is used to stage the presence of colorectal cancer. CEA may be elevated in colorectal cancer but isn't considered a confirming test. RATIONALE: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

RATIONALE: Considering the circumstances surrounding these symptoms, they most probably signal a panic attack, which is a period of intense fear or discomfort that develops abruptly, and peaks in 10 minutes. An allergic reaction would have a precipitating cause and may also include a cutaneous reaction or edema. An MI would involve chest pain or cardiac compromise. Hypoglycemia rarely includes shortness of breath but would need to be differentiated by obtaining the client's blood glucose level. RATIONALE: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

RATIONALE: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake. RATIONALE: Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if the feeding requires it. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings. RATIONALE: Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess. RATIONALE: In osteoarthritis, osteophytes form in joint spaces. Narrowing of joint spaces or margins, cystlike bony deposits in the joints, and long-bone growths at weight-bearing areas are other X-ray findings. RATIONALE: Most accidents occur in the home and safety devices are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or picking up objects. Protective devices aren't usually necessary for the client to perform exercises. RATIONALE: Eggs, bread, and tea are foods that have low potassium content. The other foods are high in potassium.

RATIONALE: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of the total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body. RATIONALE: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. RATIONALE: The peak incidence of testicular cancer in men occurs between ages 15 and 40. RATIONALE: The breasts are least tender and have fewer nodules 1 week after menstruation starts. Before the onset of menstruation, breasts may be most tender and nodular. Examining the breasts every day or after every shower is excessive and unnecessary. RATIONALE: Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes, Bouchard's nodes, and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Heberden's nodes are bony growths that occur at the distal interphalangeal joints. Bouchard's nodes involve the proximal interphalangeal joints. Tophi are deposits of sodium urate crystals that occur in chronic gout face; not osteoarthritis. Hot, inflamed joints rarely occur in osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury. RATIONALE: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP by increasing intrathoracic pressure and reducing venous return. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP. RATIONALE: Familial polyposis is a strong risk factor for colorectal cancer. In addition, the risk of developing colorectal cancer increases after age 50. Certain cancers, such as genital or breast cancers, are risk factors for colorectal cancer. Gastric ulcers rarely become malignant and aren't associated with colorectal cancer. A high-fat, high-calorie diet also increases the risk of colorectal cancer. Other risk factors for colorectal cancer include inflammatory bowel disease and a history of colorectal cancer. RATIONALE: An irrigation bag should be elevated 18 inch to 20 inch (45 to 50 cm) above the stoma. Typically, adults use 500 to 1,000 ml of water at a temperature no higher than 105 F (40.6 C) to irrigate a colostomy. If cramping occurs during irrigation, the irrigation should be stopped and the client told to

take deep breaths until the cramping stops. The irrigation can then be resumed. Hand washing reduces the spread of microorganisms. RATIONALE: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option a requires a yes-orno response and is self-limiting. In Option b, the nurse is telling the client what to think and feel. Option d dismisses the client's feelings. RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety. RATIONALE: Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as frequently or as commonly as diarrhea. RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity. RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.

RATIONALE: Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren't appropriate for treating panic attacks. RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what's going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities. RATIONALE: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation. RATIONALE: The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and

preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity. RATIONALE: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ml, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and pill rolling. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing. RATIONALE: Focusing on the client's blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. To promote selfesteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren't under the client's control and are real to him. Eye exercises won't resolve the client's blindness because no organic pathology is causing the symptoms. RATIONALE: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior. RATIONALE: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It's important for the child to find a way to express internalized feelings. The child must also know that he isn't to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy. RATIONALE: The foundation of any treatment for alcoholism is abstinence. Attendance at AA is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking.

RATIONALE: The defining characteristics are those of chronic low self-esteem. The definition of this diagnosis is negative self-evaluation, along with negative feelings about self or capabilities, which may be directly or indirectly expressed. Anxiety, ineffective denial, and ineffective individual coping all have different sets of defining characteristics. RATIONALE: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. Insight is comprehension of one's own behavior, often followed by an attempt to change it. Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness. Based on the information provided, the client doesn't seem to be manipulating those around her. RATIONALE: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain & not loss & is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants. RATIONALE: By talking about returning to college, the client is demonstrating an interest in making plans for the future, which is a sign of recovery from depression. Decreased socialization, lack of interest in personal appearance, and lack of emotion are all symptoms of depression. RATIONALE: Because of the risk of missing an actual medical problem, any new symptoms reported by a client with hypochondriasis should be reported to the physician. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder. RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse & not the client & should judge what specific information must be shared with others on the health care team. RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions; therefore, the client's mouth would feel dry. Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than 48 beats/minute). Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep. RATIONALE: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The nurse should continually reorient the client to time and place as he

wakes up from the procedure. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented. RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal. RATIONALE: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency. RATIONALE: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

RATIONALE: Benztropine mesylate is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine drug, is administered to reduce anxiety. RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.

RATIONALE: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory. RATIONALE: The nurse must check extremities for signs of circulatory impairment. Measuring urine output isn't crucial; the client may void into a urinal as necessary. Assessing pupillary responses isn't relevant to the situation. Although the nurse should check vital signs every 15 minutes for 1 hour, assessment for circulation takes priority over respiratory pattern.

RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. The other options are important assessments, but the client's danger to himself or others takes priority. RATIONALE: The nurse should look for consistency in subjective and objective data. Falling asleep, cessation of verbal threats, and saying that he's okay may indicate that restraints are no longer needed, but the nurse needs more data than any one of these options provides. RATIONALE: This response acknowledges that the client is important to the nurse and preserves the client's dignity with minimal restriction. The client doesn't need to be escorted to his room at this point; he hasn't yet been given a chance to go on his own. The nurse should use the least restrictive form of treatment at all times. Facing off with the client and demanding quiet is challenging. Telling the client to calm down is a placating response, which will likely increase the client's anxiety. RATIONALE: This question aims to clarify the client's remark. Option A ignores what the client said and violates the client's right to the least restrictive environment. Option B assumes that the client is hallucinating. Option C fails to address what the client said. RATIONALE: The nurse's open-ended response encourages exploration. Option A is placating the client. Option B is threatening or, at least, too restrictive because the client hasn't exhibited dangerous behavior. Option C assumes that the client is afraid. RATIONALE: Administering these two medications within a short time frame increases the risk of hypertension and hyperpyrexia. Dosages of MAO inhibitors can vary widely. The client's suicidal state and his allergy to cheese are irrelevant to the choice of drug or timing of administration. RATIONALE: MAO inhibitors, such as tranylcypromine, may take up to 4 weeks before improving the client's mood. Telling the client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Consulting the physician is premature.

RATIONALE: A client taking an MAO inhibitor must avoid tyramine-rich foods to prevent a hypertensive or hyperpyretic crisis. Fluid intake, potential for self-harm, and level of anxiety are important assessment areas, but they don't relate directly to the clients' understanding of medications. Madeleine Leininger's conceptual model of nursing (1978) has a key emphasis that caring is universal and varies transculturally. According to Alfaro-Lefevre (1955), when providing nursing care, the nurse makes clinical judgments about the client's care based on fact, experience, and standards of care. Under the managed care system, the organization that pays for health care has the capacity to influence who provides client care, how the care is furnished, and who receives compensation. The federally funded national health insurance program in the United States for persons older than age 65 is Medicare. The ANA Standards of Professional Performance describes a competent level of behavior in the professional nurse's role. The six levels of the health care system are preventive, primary, secondary, tertiary, restorative, and continuing care. Culturally congruent care is meaningful, supportive, and facilitative because it fits the valued life patterns of the client. Some components of cultural assessment that provide insight into the type of information that may be useful in planning and delivering care are heritage and ethnohistory, religious and spiritual beliefs, and communication patterns. Ethnocentrism, a tendency to place one's own way of life as superior to others, is the root of biases and prejudices comprising beliefs and attitudes associating negative permanent characteristics with persons who are perceived to be different from the valued group.

The physiology of pain includes four processes. These are transduction, transmission, perception, and modulation. In the "gate control" theory of pain, gating mechanisms can be found in substantia gelatinosa cells within the dorsal horn of the spinal cord and the thalamus.

The point at which a person becomes aware of pain is perception.

Jean Piaget's theory of cognitive development includes four periods (sensorimotor, preoperational, concrete operation, and formal operations) and recognizes that children move through these specific periods at different rates but in the same sequence. Comprehensive client education includes three important purposes: Health maintenance and promotion of health and illness prevention, restoration of health, and coping with impaired functioning. Core temperature measurement sites include rectum, tympanic membrane, and urinary bladder. An involuntary response to temperature differences in the body that can increase heat production four to five times greater than normal is shivering. Status epilepticus, acute prolonged seizure activity that occurs without full recovery of consciousness between attacks, is a medical emergency and is considered the major complication of seizures. When assisting a client out of bed, the nurse should move the client's head and shoulders to the edge of the bed, move the client's feet and legs to the edge of the bed, place both arms well under the client's hips, tighten the muscles in the back, and straighten the back while moving the client. The longest segment of the digestive tract is the small intestine. The primary functions of the liver are to break down and store many biological molecules, store vitamins and iron, destroy old blood cells, produce bile to aid digestion, and destroy poisons that enter the body. The largest organ system of the body is the skin. There are 206 bones in the human body. They are categorized as long bones, short bones, flat bones, and irregular bones. The federal agency responsible for monitoring endemic and epidemic disease is the CDC. A nosocomial infection is one that is acquired in the hospital. The patellar reflex is elicited by the examiner striking the patellar tendon just below the patella. The middle ear contains the three smallest bones in the body- the malleus, incus, and stapes. The winding, snail-shaped bony tube that forms a portion of the inner ear and contains the transducer for hearing is the cochlea.

If a prescriber orders a medication to be taken by the client when required, this is a PRN medication order. The International Classification of Seizures differentiates between two main types: Partial and generalized seizures. In complex partial seizures, the nurse should expect that the client will remain motionless or move inappropriately for time and place and that the client will not remember the episode. Although the listed drugs have similar sounding names, the only one that is an antiseizure medication is lamotrigine (Lamictal). Epilepsy is defined as a group of syndromes characterized by recurring seizures. After a seizure has begun, the primary steps the nurse should take include providing privacy, easing the client to the floor if possible, and protecting the client's head. Chest pain may occur in clients with pneumonia, pulmonary embolism, and pleurisy. It is commonly a late symptom of bronchogenic carcinoma. Adventitious or additional breath sounds, caused by abnormal conditions that affect the bronchial tree and alveoli, are categorized as discrete, noncontinuous, and continuous. Crackles (formerly called rales) are considered a discrete, noncontinuous breath sound that results from delayed reopening of deflated airways. Inspiratory and expiratory breath sounds that are about equal and are often heard in the first and second interspaces anteriorly and between the scapula are bronchovesicular sounds. On assessment, a very subtle finding heard only in the presence of dense consolidation of the lungs due to enhanced transmission of high-frequency components of sound is whispered pectoriloquy. In a client with metabolic alkalosis, the nurse should expect to find a high pH, high HCO?, and a high or normal PaCO?. In a client with respiratory acidosis, the nurse should expect to find low pH, high or normal HCO?, and a high PaCO?. In a client with respiratory alkalosis, the nurse should expect to find a high pH, low or normal HCO?, and a low PaCO?. Approximately 1 in 5 people in the United States have some form of disability.

The client is the key member of a rehabilitation team. The percentage of the end-diastolic volume that is ejected with each stroke is called ejection fraction. The two most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. A life-threatening central nervous system dysfunction resulting from liver disease and frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma is hepatic encephalopathy. The primary mode of transmission for hepatitis A is the fecal-oral route. In hepatitis A, severe anorexia is an early symptom and is thought to be caused by release of a toxin from the damaged liver or by failure of the damaged liver cells to detoxify an abnormal product. Most people who contract hepatitis B develop antibodies to the infection and recover in about 6 months, but the mortality rate is approximately 10%. When assessing a severely ill client with liver dysfunction, the nurse notices a flapping tremor of the hands and documents this as asterixis. When assessing a severely ill client with liver dysfunction, the nurse detects a sweet, slightly fecal odor of the client's breath known as fetor hepaticus. An example of an exocrine gland is the sweat glands. Both Addison's disease and Cushing's syndrome result from an imbalance of cortisol and aldosterone. The type of diabetes mellitus previously referred to as non-insulin-dependent diabetes mellitus is type 2 diabetes mellitus. The highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin is ketone. Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors used to treat type 2 diabetes mellitus. Three major acute complications of diabetes mellitus are hypoglycemia, DKA, and hyperglycemic hyperosmolar nonketotic coma or HHNS. Five components of diabetes mellitus management are nutritional management, exercise, blood glucose monitoring, pharmacologic therapy, and client education.

Giving a client with acute hypoglycemia approximately 20 g of a simple carbohydrate is approximately equal to 4 ounces of orange or grapefruit juice, two sugar cubes, or seven Life Savers. An eye condition caused by differences in the curvature of the cornea and lens, leading to refractive error in which light rays are spread over a diffuse area rather than sharply focused on the retina is astigmatism. The bone matrix stores calcium, phosphorus, magnesium, and fluoride. Clients with decreased calcium regulation and metabolism are at risk for osteoporosis and pathologic bone fractures due to weakened bone tissue.

In a client with a urinary tract infection, a fetid urine odor is commonly associated with Escherichia coli. In the renin-angiotensin system, the stimuli for renin secretion are decreased renal perfusion pressure and/or decreased salt delivery to the kidney tubules. An important nursing action in preparing a client for urologic testing with a contrast agent is to obtain the client's allergy history, especially to iodine, shellfish, and other seafood, because many contrast agents contain iodine. The nurse should never clamp a client's nephrostomy tube. In all types of acute renal failure, the client's serum creatinine level is increased. The term that refers to the body's specific protective response to an invading foreign agent or organism is immunity One function of the spleen is to destroy old and injured red blood cells. The nurse should expect that the major symptom in the B- and T-lymphocyte disorder Wiskott-Aldrich syndrome is thrombocytopenia. A full-thickness burn is described as one that involves the epidermis, entire dermis, sometimes subcutaneous tissue, and possibly connective tissue, muscle, and bone. Legionnaires' disease is describes as a multisystem illness that usually includes pneumonia and is caused by the gram-negative bacteria Legionella pneumophila. The test for cerebellar dysfunction that requires the client to stand with feet together, eyes closed, and arms extended is the Romberg test.

Actions of dopamine, a major neurotransmitter, include helping to control mood and sleep and inhibiting pain pathways. The preferred method of taking a temperature of an unconscious client is rectal or tympanic if not contraindicated. Cerebral edema is abnormal accumulation of water or fluid in the intracellular space, extracellular space, or both associated with an increase in brain tissue volume. When assessing a client with an ear disorder, the nurse should ask about use of ototoxic drugs, such as aminoglycoside antibiotics, antimalarials, and diuretics such as furosemide (Lasix). One framework for understanding the individuality of the dying process describes the patterns of living while dying. The originator of this framework is B.C. Martocchio (1982). Non-antibody proteins that act as intracellular mediators especially in immune responses, are cytokines. Most immune responses to antigens involve a specific type of response. During transplantation rejection, the cellular response dominates. A person's unique genetic constitution is made up of 30,000 to 40,000 genes and is called a genotype. RATIONALE: The circulating nurse is responsible for the overall running of the OR before, during and after the operative procedure. Also he/she is responsible for the opening of the outer wrapper of sterile supplies that will be used during the operative procedure. OPTION B: The anesthesiologist is the person that administers the anesthetic to the patient. OPTION C: The surgeon is responsible in performing the surgical procedure safely and correctly. OPTION D: The nursing aide is not a part of the surgical team. RATIONALE:Anesthetist is the answer. Sterile team are perioperative caregivers who provide direct care within the sterile field. Nonsterile team are perioperative caregivers who provide direct care from the pheripery of the sterile field and environment. An Anesthetist is a member of the nonsterile team who administers anesthetics during the surgical procedure OPTIONS A, B & D: Sterile members of the surgical team RATIONALE:Normal saline solution is the only solution compatible for blood transfusion OPTION A: is not for blood transfusion OPTION B: Solutions containing calcium, such as Ringer's lactate may cause clotting. OPTION C: Dextrose may lead to clumping of red blood cells and hemolysis. RATIONALE: Regardless of its source, pain that is inadequately treated as harmful has harmful

effects beyond the discomforts it causes. Unrelieved pain affects various body systems, including the cardiovascular system, and can initiate the stress response, resulting in increased pulse and BP and a distressed appearance. By providing an explanation such as this, the nurse can help the patient to accept the drugs needed to relieve pain. OPTION A: Patients have the right to refuse therapy. The nurse can play an important role in determining the reason for refusal and should first make that attempt before accepting refusal. OPTION C: A general principle for administering analgesics is to administer them before pain increases in severity. OPTION D: Medications should never be left at the bedside for the patient to take later. RATIONALE: fentanyl (sublimaze) is a narcotic agonist analgesic (Other name: Neuroleptanalgesic) It is 75-100 times more potent than morphine! In very high doses it can cause respiratory depression. Assess respiratory rate to monitor impending signs of respiratory depression. RATIONALE: Using ABC, airway patency is the priority during postoperative pneumonectomy OPTIONS B, C & D: correct intervention but airway patency is still the priority RATIONALE: Patient safety in the preoperative area is a priority. Using process to verify patient identification, the surgical procedure, and the surgical site maximizes patient safety and allows for early identification and intervention if any discrepancies are identified. RATIONALE: It is the responsibility of the surgeon and the anesthetist or anesthesiologist to monitor and manage complications. However, a nurse plays an important role. Being alert to and reporting changes in vital signs and symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyperthermia and disseminated intravascular coagulation and assisting with their management is an important factor (Smeltzer, 434). The anesthesia provider functions as the guardian of the patient throughout the entire care period, the anesthesia provider manage the patient's physiology using the principle of aseptic technique (Phillips, 51). Maintaining the patency of airway is the responsibility of the anesthesia provider, an accidental removal of airway is negligent. RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery. These patients should be counseled to stop smoking at least 24 hours prior to surgery. Research suggest that counseling has a positive effect on the patient's smoking behavior 24 hors preceding surgery, helping reduce the potential for adverse effect associated with smoking such as increased airway reactivity, decreased mucocilliary clearance, as well as physiologic changes in the cardiovascular and immune systems. RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended.

RATIONALE: Following breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. The nurse would also document the findings once the physician is notified. OPTIONS B & C: are incorrect actions. RATIONALE: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are first used to prompt relief of airflow obstruction. OPTION A: This is not a priority OPTION B: Should only be at 2L/min OPTION C: Suctioning the client increases respiratory distress RATIONALE: Status asthmaticus is severe persistent asthma that does not respond to conventional therapy. The attacks last longer than 24 hours. The basic characteristic of asthma decreases the diameter of the bronchi and is apparent in status asthmaticus. A ventilationperfusion abnormality results in hypoxemia and respiratory alkalosis initially, followed by respiratory acidosis. There is a reduced PaO2 and an initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and pH falls, reflecting respiratory acidosis. RATIONALE: The first ECG signs of acute MI are from myocardial ischemia and injury. Myocardial injury causes a T wave to become enlarged and symmetric. As the area of injury becomes ischemic, myocardial repolarization is altered and delayed, causing the T wave to invert. The ischemic region may remain depolarized while adjacent areas of the myocardium return to resting state. Myocardial injury also causes ST-segment changes. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells, causing the ST segment to rise at least 1 mm above the isoelectric line (area between the T wave and the next P wave is used as a reference for isoelectric line) when measured 0.08 seconds after the end of the QRS. RATIONALE: QRS complex represents ventricular muscle depolarization OPTION B: T wave represents ventricular muscle repolarization OPTION D:P wave represents atrial muscle depolarization RATIONALE: GERD is the backflow of gastric or duodenal contents into the esophagus caused by incompetent lower esophageal sphincter. Pyrosis or heartburn, dyspepsia and dysphagia are cardinal symptoms. RATIONALE:The QRS is normally less than 0.12 seconds in duration

RATIONALE: When difficulty of swallowing is accompanied with pain this is now referred as odynophagia OPTION D - Dysphagia is difficulty of swallowing alone. RATIONALE: There are techniques that the nurse can use to reduce odor of the ileostomy, such as placing charcoal in the ileostomy bag. The charcoal will absorb the odor in the bag. OPTION A - the odor does not gradually become less noticeable unless steps are taken to reduce it. OPTION B - While it is important to help the patient ventilate, this response does not answer the issue of the odor. OPTION D - This statement is not necessarily true. Others may be offended by the odor. Teaching the patient measures that will help to reduce odor will be most beneficial. RATIONALE: If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Painful cramps are often caused by too rapid flow or by too much solution. 300 ml of fluid maybe all that is needed to stimulate evacuation. Volume may be increased with subsequent irrigation to 500, 1000, or 1500ml as needed by the patient for effective results. RATIONALE: Convenience sampling - selection of the most readily available persons as participants in the study; also known as accidental sampling. OPTION A: Purposive sampling - a non-probability sampling method in which the researcher selects participants based on personal judgment about which one will be most representative or informative; also known as judgmental sampling OPTION C: Snowball sampling is the selection of participants through referrals from other participants; also known as network sampling OPTION D: Quota sampling - a nonrandom selection of participants in which the researcher prespecifies characteristics of the sample to increase its representative RATIONALE: Random sampling is a selection of the sample such that each member of the population has an equal probability of being included. RATIONALE: The surgical wound may be closed with sutures, staples and other materials or may be left open to heal by secondary intention. Common skin closures are the following: continuous suture, interrupted suture, staples, skin strips, retention suture and buried suture. RATIONALE: The surgeon is the head of the surgical team and is the one making decisions about the surgery. RATIONALE: Probanthine reduces glandular secretion of the different organs of the body. It is an anticholinergic/antispasmodic drug and still, not approved by the FDA for treatment with various disorders. Probanthine exerts benefits for treatment of severe diaphoresis, Ulcers due to over secretion of HCl, Spasms, PANCREATITS [Please take note] and other conditions of over

secretion. RATIONALE: Probanthine on its own already cause severe dizziness and drowsiness. Addition of alcohol will further depress the CNS and might lead to potentiation of the side effects of probanthine. OPTIONS A, B & C are not contraindicated when taking probanthine EXCEPT when the disease entity itself do not permit intake of such drugs like in Pancreatitis, NSAID is not use. Pain is controlled using probanthine and meperidine (Demerol) in cases of acute pancreatitis. RATIONALE: Probanthine alters the ability of the body to secrete sweat. Telling the client to avoid hot weathers to prevent heat stroke is appropriate. OPTION B: Chlorinated pool is discouraged for patients undergoing skin radiation for skin cancer to prevent breakdown. OPTIONS C & D: Limiting fluid intake and avoiding cold weather are unecessary teachings. RATIONALE: Plasma to interstitial fluid shift usually occurs during the initial stage of burn injury; this causes leakage through the capillaries, resulting in edema. Because of cellular trauma, potassium is released into the extracellular space, causing hyperkalemia. After the initial stage, which usually lasts approximately 36 hours, the body starts to shift fluid back into the intravascular space, predisposing the patient to circulatory overload; at the same time, large amounts of potassium are excreted in the urine because of the increased intravascular volume. Aldosterone, which reabsorbs sodium and excretes potassium, is released in large quantities in response to dilutional hyponatremia, which develops as intracellular and interstitial fluid shift back into the intravascular compartment. RATIONALE: A decrease serum sodium level usually indicates dilutional hyponatremia, or water excess; the patient's water intake should be restricted to allow the kidneys to excrete the excess water. The other laboratory values do not reflect changes in water balance. RATIONALE: Deliberate attempt to lose weight during the early phase of burn therapy would keep the patient in a state of negative nitrogen balance (catabolism); this would further complicate the patient's condition because he needs to rebuild tissue. Infection control is necessary to help ensure proper healing. Fluid and electrolyte replacement helps prevent weight loss, catabolism, and the effects of fluid and electrolyte imbalances. The nurse should provide psychological support for the patient; burns commonly have negative effect on the patient's body image. RATIONALE: The patient with hypothyroidism has intolerance to cold so a warm environment should be provided. OPTION A: inappropriate OPTION B: administering medication is a dependent nursing intervention. It requires a doctor's order.

OPTION D: weight gain develops in hypothyroidism due to a slowed metabolic rate and eventually leads to edema formation. Encouraging drinking 6-8 glasses of water may further aggravate existing edema. RATIONALE: Clients with hypothyroidism must receive a lifelong thyroid replacement therapy such as (levothyroxine) Synthroid. Levothyroxine is a replacement for a hormone that is normally produced by your thyroid gland to regulate the body's energy and metabolism. Levothyroxine is given when the thyroid does not produce enough of this hormone on its own. OPTION B: An anesthetic agent OPTION C: Antilipidic agent OPTION D: A dopaminergic agent RATIONALE: A client with hypothyroidism usually feels fatigued which commonly leads to the nursing diagnosis activity intolerance related to weakness and apathy secondary to a decreased metabolic rate and resulting in an increased heart rate and shortness of breath with activity OPTION B: Appropriate nursing diagnosis for hyperthyroidism. Exophthalmus is seen in hyperthyroidism OPTION C: Appropriate nursing diagnosis for hyperthyroidism. In hypothyroidism there is hypometabolism not hypermetabolism. OPTION D: Appropriate nursing diagnosis for hyperthyroidism. In hypothyroidism there is constipation not diarrhea RATIONALE: Lying prone with the head of the bed lowered 15-30 degrees will make the fluid settle on the upper areas of the lungs by gravity. In thoracentesis, position the patient comfortably with adequate supports. If possible, place the patient upright or in one of the following positions: Sitting on the edge of the bed with the feet supported and arms ad on a padded over-the bed table Straddling a chair with arms and head resting on the back of the chair lying on the unaffected side with the bed elevated 30 degrees to 45 degrees if unable to assume a sitting position The upright position facilitates the removal of fluid that that usually localized at the base of the chest. A position of comfort helps the patient to relax. RATIONALE: The use of side rails has been a routine practice with the rationale that the side rails serve as a safe and effective means of preventing clients from falling out of bed. OPTION A: inappropriate because the patient is going to sleep. Does not address safety. OPTION C: Does not answer safety in bed concern OPTION D: Locking the door does not provide bed safety RATIONALE: The nurse's immediate response is to ensure compliance with currently ordered

intravenous fluids. OPTIONS A & B: are wrong actions OPTION D: Although an unusual occurrence should be filed, it is not a priority RATIONALE: The procedure may be under either local or general anesthesia. If a local anesthetic is used, the procedure is usually done with the person in a sitting position (more common with adults). If general anesthesia is used, the person is placed in dorsal recumbent. RATIONALE: Continuous nursing intervention is required in the immediate postoperative and recovery period because of significant risk of hemorrhage. Monitor signs of hemorrhage (frequent swallowing may indicate hemorrhage) OPTION A: Milk and milk products (ice cream and yogurt) may be restricted because they make removal of secretions difficult. OPTION B: In the immediate post operative period, the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx OPTION C: may mask bleeding RATIONALE: In the immediate post operative period, the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx All other options are incorrect RATIONALE: The creatinine clearance test is a blood and timed urine specimen that evaluates kidney function. Blood is drawn at the start of the test and the morning of the day that the 24-hour urine specimen collection is complete. RATIONALE: The IVP is a painless procedure. You will feel a minor sting as the iodine is injected into your arm. Some patients experience a flush of warmth, a mild itching sensation and a metallic taste in their mouth as the iodine begins to circulate throughout their body. RATIONALE: The iodine-based dye used in IVP can cause allergic reactions such as itching, hives, rash, a tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is a priority. OPTIONS A, B & D - Address implementation; assessment is the priority RATIONALE: Post IVP interventions: Monitor vital signs. Instruct the client to drink atleast 1L of fluid unless contraindicated. Assess the venipuncture site for bleeding Monitor urinary output. Monitor for signs of a possible allergic reaction to the dye used during the test.

RATIONALE: TPN is used to maintain nutritional status and prevent malnutrition when the patient is unable to be fed orally or by tube feeding. Glucose is used to supply energy and caloric needs and usually accounts for 50 - 70% of the nutrient prescription OPTION A: In pancreatitis, 50% of the patients have a transient hyperglycemia due to the damage to the beta cells. If the pancreas were producing too much insulin, the patient would experience hypoglycemia. Giving additional insulin would not be the correct intervention. OPTION B: 50% of patients with pancreatitis have interference with insulin release from the beta cells, which may cause hyperglycemia. Not all patients exhibit hyperglycemia. OPTION D: TPN does not interfere with the production of insulin. The goal of therapy is to reduce the secretion of pancreatic enzymes, which stops the inflammatory process. The use of TPN meets the patient's nutritional needs while the patient is taking nothing by mouth. RATIONALE: Insulin is released after ingestion and absorption of carbohydrates SOURCE: RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues. Since most of the potassium in the body is contained in muscle, a severe trauma that crushes muscle cells results in an immediate increase in the concentration of potassium in the blood. Hyperkalemia result from severe burns for the 1st 24 hours. Hyponatremia in burns occur due to low plasma osmolarity. RATIONALE: Documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse's error will not result in suspension nor will it be documented in the personnel file. The situation and the error presented in the question are not a reason for notifying the board of nursing. RATIONALE: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injury experienced by those involved, and the outcome of the situation. Option A is the only option that describes the facts as observed by the nurse. Options B, C, and D are interpretations of the situation and not factual data as observed by the nurse. Rationale: Incisional biopsy; a selected part of the lesion is removed. This form of biopsy is commonly completed During endoscopic examination. The Frozen Method procedure is used to assess for malignant cells from tissue samples. Frozen sections are used for rapid microscopic

diagnosis. A thin slice of tissue is cut from the frozen specimen and examined. The procedure requires 10-15 minutes. The pathologist can determine whether malignancy is present and whether the entire tumor has been removed by looking for a margin of tumor-free tissue. RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the development of cancer of the large bowel. Studies on bulk in stool and the rate of transit of fecal matter have so far given mixed results. Some researchers propose that metabolic and bacterial end products are carcinogenic and that constipation allows a longer contact with the bowel wall, thus raising the probability that cancer will develop. Increasing fiber in the diet may reduce exposure to carcinogens by speeding stool transit through the intestines. RATIONALE: Symptoms include the following: Blood in stools, anorexia, vomiting, and weight loss, malaise, Anemia, abnormal stools. Ascending colon tumor: Diarrhea, Descending Colon tumor: constipation or some diarrhea, or flat, ribbon-like stool resulting from a partial obstruction. Rectal Tumor: alternating constipation and diarrhea, guarding or abdominal distention, abdominal mass (a late sign), Cachexia (a late sign). RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug, primarily for the treatment of asymptomatic mengococcal carrier, can be used as alternative for penicillin in rheumatic fever. Neomycin, kanamycin sulfate, erythromycin, & succinylsulfathiazole (Sulfasuxidine) are used preoperatively to reduce bacterial number in the GI tract. Sulfasuxidine and other antiseptics and antibiotics, as prescribed to decrease the bacterial content of the colon to reduce the risk of infection from the surgical procedure.

RATIONALE: Carefully assess the client's physical condition, emotional and mental attitudes toward the colostomy before attempting to teach ostomy self-care. Pace the teaching to the client's level of acceptance of the colostomy and ability to manage it. Teach the client how to apply the pouch to the stoma correctly. The client first should be taught how to examine the stoma. A healthy stoma and abdominal incision is a very good indicator that client is now ready for ostomy care teaching.

RATIONALE: A suitable time for the irrigation is selected that is compatible with the patient's posthospital pattern of activity (preferably after a meal). Irrigation should be performed at the same time each day. RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate evacuation, Volume may be increased with subsequent irrigations to 500, 1000, up to 1, 500 mL as needed by the patient for effective results. Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Water should flow in over 5 to 10 minute period. RATIONALE: As such there is no specific diet plan for Ostomy patients. The main point is that you should be able to tolerate the food you are eating. Still certain foods you need to avoid or include in your diet so as to maintain a good health after Ostomy. Below is the list of food you need to keep in consideration: Food resulting in thickened stools (Low-Fiber): Applesauce, Peanut butter, boiled milk, Tapioca, Rice, Cheese, Bananas, and Pretzels. Food resulting in soft stools (High Fiber): Red wine, Beer, Coffee, Prune juice, Fresh vegetables, Fruits and Food with high fiber content. Foods resulting in incomplete digestion: Broccoli, Cabbage, Raw carrots, Raw onions, Pineapple, Beans, Spinach, Potato skins, Corn, Coconut, Celery, Whole grains, Nuts, Raisins, Popcorn, Raw fruits, Chinese vegetables, Seeds and Skins. Foods causing odor: Cabbage, Beans, Asparagus, Onions, Garlic, Eggs, Fish, Alcohol and Vitamins. Foods causing gas: Raw apple, Cabbage, Broccoli, Onions, Turnip, Corn, Nuts, Milk, Beer, Carbonated beverages, iced beverages and Chewing gums. Foods causing diarrhea: Fried foods, highly spicy food, Legumes, Grape juice, Apple juice, Prune juice, Green beans, Spinach, Raw fruits, Cabbage and Milk. RATIONALE: Assessment actions to check for signs of extended pneumothorax or hemothorax should be performed such as palpating surrounding areas for crepitus. It may also be an indication for a chest tube complication known as subcutaneous emphysema. Subcutaneous emphysema occurs when air gets into tissues under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other penetrations, or blunt trauma. Air can also be found in between skin layers on the arms and legs during certain infections, including gas gangrene. Subcutaneous emphysema can often be seen as a smooth bulging of the skin. When a health care provider feels (palpates) the skin, it produces an unusual crackling sensation as the gas is pushed through the tissue.

RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall as a result of the inflammation of the vessel wall. It has 3 Types: Superficial, Femoral, and Pelvic. Assessment findings for a developing Superficial Thrombophlebitis are tenderness and pain in the affected lower extremity. Also includes the following symptoms: warm and pinkish red color over the thrombus area, palpable thrombus that feels bumpy and hard. RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or tonsillitis 2 - 3 weeks before symptoms. Usually a streptococcal infection may precede it. It is very important to seek treatment for respiratory infections existing to stop the progress of the disease. And it is usually with untreated respiratory infections (Group A ?-hemolytic streptococcus) that this sequelae develop. OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria from entering the urethra, however is indicated for UTI. OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is more of an intervention rather than a preventive measure for recurrence. OPTION D: Avoiding physical activity is also an intervention for Glomerulonephritis. RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM, IgG, IgA, IgD, and IgE, which are essential in the body's defense against microorganisms. Household and personal contacts of clients with HAV should be given immune globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and after exposure. However a specific vaccine had been developed for Hepatitis A which is the inactivated hepatitis A vaccine (active), which is given two doses of at least 6 months apart for persons who reside in a community that has a high rate of hepatitis A virus infection, who are at risk because of foreign travel, or who have chronic liver disease. RATIONALE: It is most important to watch out for signs of infection because a patient in TPN is most prone to infection because of an open venous access that can be easily contaminated; furthermore, microorganisms can easily find its way to enter the body through the bloodstream. A strict aseptic technique must be used because the TPN solution has a high concentration of glucose, which is a medium for bacterial growth. Signs of an infection are as follows: Chills, elevated WBC count, erythema or drainage at the insertion site, and fever. Assess IV site for

redness, swelling, tenderness, or drainage. Change IV tubing every 24 hours or according to agency protocol. If signs of infection occur at the site, the following must be done: IV line must be removed and restarted at a different site Remove the tip of the IV catheter and send it to the laboratory for culture Prepare the client for blood cultures RATIONALE: The Gram-Stain is the most important of all bacteriologic differential stains to diagnose a wound infection. It divides bacteria into two physiologic groups: Gram - and Gram + organisms, thus determining the type of medication to be given to the patient. Infectious diseases or processes can be diagnosed by detection of an immunologic response specific to an infecting agent in a patient's serum. Normal humans produce both IgM ( first-response antibodies) and IgG (antibodies that may persist long after an infection) to most pathogens. (Frances Fischbach's A manual of Laboratory and Diagnostic Tests 7th edition, p. 500) RATIONALE: It is important to get the attention of the client before beginning to speak despite it's inability to respond or to react, nurse must move close to the client and speak slowly and clearly, talking in lower tones is advised as shouting may not help and may only disturb other clients inside the unit. Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, RATIONALE: Mitigation - actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of one Involves determining community hazards and risks (actual and potential threats) for the occurrence of a disaster Involves identifying available community resources and community-health personnel Involves determining the resources available for care of infants, older clients, the disabled, and those with chronic health problems Recovery: Includes actions taken to return to normal after the disaster. Includes prevention of debilitating effects and restoration of personal, economic, and environmental health and stability to the community Response: Involves putting disaster-planning services into action and enumerating the actions needed to save lives and prevent further damage. Primary concerns include the safety and physical and mental health of both the victims and the members of the disaster-response team Preparedness: Includes plans for rescue, evacuation, and care of disaster victims Includes plans for training disaster personnel and gathering resources, equipment, and other materials needed for dealing with the disaster

Includes identification of specific responsibilities for various disaster-response personnel Establishes a community disaster plan and an effective public-communication system Involves setting up an emergency medical system and a plan for its activation Includes checking proper functioning of emergency equipment Involves making anticipatory provisions and setting up a location for distribution of food, water, clothing, shelter, other supplies, and medicine Includes checking supplies on a regular basis and replenishing those that have become outdated Includes practicing community disaster plans (mock-disaster drills) RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated. They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (examples: broken bones without compound fractures, many soft tissue injuries). Option A:Yellow Tag: Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances). OPTION B: Red Tag: They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. OPTION C: Black Tag: They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in lifethreatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be taken to a holding area and given painkillers as required to reduce suffering. RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated cautiously. Gloves shall be worn when cleaning up blood spills or other bodily fluid spills. These spills shall be disinfected with a ten percent bleach solution or an approved cleansing solution. Bleach primarily is used to disinfect blood spills on various surfaces, they are composed of various chemical components one of which is Sodium Hypochlorite. A 1 in 5 dilution of household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria and some viruses, and is often the disinfectant of choice in cleaning surfaces in hospitals. The solution is corrosive, and needs to be thoroughly removed afterwards, so the bleach disinfection is sometimes followed

by an ethanol disinfection. RATIONALE: Learning need is a desire or a requirement to know something that is presently unknown to the learner. A comprehensive assessment of learning needs incorporates data from the nursing history and physical assessment and addresses the client's support system. It also considers client characteristics that may influence the learning process: readiness to learn, motivation to learn, and reading or comprehension level, for example. Assessment of learning need is done first before developing a teaching plan. OPTION D may be done at later part of learning. RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. RATIONALE: The nurse may feel conflict because the nurse wants the client to share important information but is unsure about making such promise. The information may be important to the health or safety of the client or others. Let the client decide whether to share the information or not. The family is the primary system to which a person belongs, and in most cases, it is the most powerful system to which a person may ever belong. Birth, puberty, marriage, and death are all considered to be family experiences. The family can be the source of love or hate, pride or shame, security or insecurity. OPTIONS: A - Wrong delegation B & C - Let the client decide whether to share the information or not. RATIONALE: In this age the patient is aware that death will soon occur. Look at the statement. OPTIONS A,B and C - Destructors Situation 12 - Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment. RATIONALE: Bowel softener promotes bowel evacuation without straining / Valsalva's maneuver because it increases ICP. Straining during coughing, movement in bed or moving bowels increases ICP.

OPTION B - Positioning the client with his head towards the side of the tumor increases pressure on the tumor and increases or produces pain. OPTION C - Noise and frequent interruptions may decrease needed sleep and alter ability to cope. OPTION D - Coughing increases ICP. RATIONALE: Straining during coughing, movement in bed, moving bowels or Valsalva Maneuver increases ICP. ( SOURCE: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 2089) OPTION A - Facilitates venous drainage from the brain. OPTION B - Hyperventilation had been recommended as the primary treatment of head injured clients because carbon dioxide causes cerebral blood vessels to dilate. By manually hyperventilating or increasing the ventilator settings to cause hyperventilation, a hypocarbic (low carbon dioxide) blood level is created. A partial pressure of C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels, leading to decreased blood flow thus decreased ICP. OPTION C - Osmotic diuretics such as Mannitol, is used to expand immediately the volume of plasma that increases blood flow and oxygen delivery. Mannitol has a delayed effect of creating an osmotic gradient and pulls fluid out of the cells, creating diuresis over the following hours. Thus reduces cerebral edema. RATIONALE: In order for an informed consent to be valid, three basic criteria must be met. The patient's decision must be voluntary, the patient must be informed, and the patient must be competent to understand the information and alternatives. The registered nurse's signature as a witness indicates these criteria were met. OPTION B - for informed consent to be valid, it must be obtained before the administration of the patient's preoperative medication. OPTION C - The patient needs only to understand the information and alternatives, not describe the procedure. OPTION D - Making a voluntary decision to have a procedure performed is only part of an informed consent. RATIONALE: The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of infectious tuberculosis is much higher for persons who are

immunosuppressed. Patients need to be taught to cover their mouth when coughing, because tuberculosis is spread by droplets. (SOURCE: CGFNS guide 5th edition; pp. 59) OPTION B - For a definite diagnosis of TB, a positive sputum culture is necessary. A Mantoux test identifies individuals exposed to Mycobacterium tuberculosis. This test does not differentiate between active and dormant infection. OPTION C - Antimycobacterial therapy is usually prescribed for six to nine months. Short term use of antibiotics is not effective chemotherapy. OPTION D - BCG strengthens the body's immune system. RATIONALE: Alcohol withdrawal begins within four to six hours of cessation of, or reduction in, heavy and prolonged alcohol use. By knowing when the patient had her last drink, the nurse can anticipate withdrawal symptoms and intervene inappropriately. OPTION A - This information will be use when the individual begins counseling. If the patient has a husband who enables her drinking, it will be much more difficult for her to quit. OPTION C - Knowing how old the patient was when she started drinking provides information on the length of her addiction. However, it is not a question that needs to be asked immediately. OPTION D - The nurse should be aware of what the patient has eaten prior to admission since food may slow down the absorption of alcohol and thereby delay withdrawal. However, the most essential assessment for the nurse to make is determining when the patient had her last drink. RATIONALE: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The normal blood pH is 7.35 - 7.45; the normal pCO2 is 38-42 mmHg; and the normal bicarbonate level is 24 - 26 mEq /L. OPTION B - This arterial blood gas indicates respiratory acidosis. OPTION C - This is a normal arterial blood gas OPTION D - This arterial blood gas indicates metabolic acidosis. RATIONALE: Not included among the risk factors. OPTIONS B, C & D - are all risk factors of cervical cancer. Human papilloma virus (HPV) is the leading cause of cervical cancer. Other factors are Low socioeconomic status, Untreated chronic cervicitis,STD's and Having a sexual partner with a history of penile or prostate cancer. RATIONALE: Lymphedema develops in clients with missing or impaired lymphatic system. Trauma, neoplasms, filariasis, inflammation, surgical excisions, or high doses of radiation are factors that develops lymphedema. OPTION A - Late manifestations. Together with pressure on the bowel, bladder or both. Bladder iiritation, Rectal discharge manifestation of ureteral obstruction and heavy aching abdominal pain. OPTION B - Pain is late manifestation. It usually becomes a difficult problem with the onset of cachexia, or general wasting syndrome.

OPTION C as well.

Vaginal discharges and bleeding especially after intercourse are late manifestations

Because Mr. Pakyaw's loss of appetite causes him to eat less than normal, he should make every mouthful count by eating high calorie foods. OPTION A - moderate activity increases persons appetite. OPTION B - Forcing fluids typically causes a feeling of fullness; this would further reduce the patients appetite and nutritional intake. OPTION D - He should avoid hot meat dishes, which commonly cause a metallic taste in the patient receiving radiation therapy. RATIONALE: Pancytopenia refers to depression in all the blood's cellular elements; the patient on Melphalan (Alkeran) therapy would probably have a reduced WBC count. OPTIONs A & C - Temporary alopecia and mild thrombophlebitis at the infusion site are adverse effects of melphalan therapy, but they are not related to pancytopenia. OPTION B - Skin pigmentation is governed by melanocytes, which are controlled by pituitary gland; because melphalan affects bone marrow production of blood cells, the drug would cause skin pigmentation changes. RATIONALE: Complications of fractures include infection, compartment venous thrombosis and fat embolism. (Source: CGFNS study guide 5th edition; pp 323) syndrome,

OPTION A & C - Electrolyte imbalance and fluid volume deficit may occur post-surgery but they are not evident in the immediate post-fracture period. OPTION - Disuse Syndrome may occur late into the post fracture period but is not seen immediately. RATIONALE: Itching under the cast can be extremely uncomfortable. The patient may be tempted to slip an object under the cast to scratch. This is a dangerous practice because of the possibility of breakage and / or skin irritation. Guided imagery is a way to help patients distract themselves from their pain and may produce relaxation response. (Source: CGFNS study guide th 5 edition; pp 324) OPTION B - Heat increases itching due to vasodilation. OPTION C - Elevation prevents dependent edema. OPTION D - Inability to move the toes indicates compression. The cast may be too tight if the patient is unable to move his / her toes. RATIONALE: The first step a nurse should take when a blood lithium level is 1.6 mEq/ dL

above is to withhold the lithium dose. (Source: CGFNS study guide 5 edition; pp 324) OPTION A - The physician should be called to re-evaluate the dose after the nurse has the results of a redrawn lithium level. OPTION C - Vital signs may be helpful in assessing if the patient is dehydrated, which can cause an increase in lithium levels. However this should be the initial action by the nurse. OPTION D - The nurse should recheck the lithium level after withholding the dose of lithium.