Bullets (FUNDAMENTALS OF

NURSING)
1. A blood pressure cuff thats too narrow
can cause a falsely elevated blood
pressure reading.
2. When preparing a single injection for a
patient who takes regular and neutral
protein Hagedorn insulin, the nurse should
draw the regular insulin into the syringe
first so that it does not contaminate the
regular insulin.
3. Rhonchi are the rumbling sounds heard on
lung auscultation. They are more
pronounced during expiration than during
inspiration.
4. Gavage is forced feeding, usually through
a gastric tube (a tube passed into the
stomach through the mouth).
5. According to Maslows hierarchy of
needs, physiologic needs (air, water, food,
shelter, sex, activity, and comfort) have
the highest priority.
6. The safest and surest way to verify a
patients identity is to check the
identification band on his wrist.
7. In the therapeutic environment, the
patients safety is the primary concern.
8. Fluid oscillation in the tubing of a chest
drainage system indicates that the system
is working properly.
9. The nurse should place a patient who has
a Sengstaken-Blakemore tube in semi-
Fowler position.
10. The nurse can elicit Trousseaus sign by
occluding the brachial or radial artery.
Hand and finger spasms that occur during
occlusion indicate Trousseaus sign and
suggest hypocalcemia.
11. For blood transfusion in an adult, the
appropriate needle size is 16 to 20G.
12. Intractable pain is pain that incapacitates a
patient and cant be relieved by drugs.
13. In an emergency, consent for treatment
can be obtained by fax, telephone, or other
telegraphic means.
14. Decibel is the unit of measurement of
sound.
15. Informed consent is required for any
invasive procedure.
16. A patient who cant write his name to give
consent for treatment must make an X in
the presence of two witnesses, such as a
nurse, priest, or physician.
17. The Z-track I.M. injection technique seals
the drug deep into the muscle, thereby
minimizing skin irritation and staining. It
requires a needle thats 1 (2.5 cm) or
longer.
18. In the event of fire, the acronym most
often used is RACE. (R) Remove the
patient. (A) Activate the alarm. (C)
Attempt to contain the fire by closing the
door. (E) Extinguish the fire if it can be
done safely.
19. A registered nurse should assign a
licensed vocational nurse or licensed
practical nurse to perform bedside care,
such as suctioning and drug
administration.
20. If a patient cant void, the first nursing
action should be bladder palpation to
assess for bladder distention.
21. The patient who uses a cane should carry
it on the unaffected side and advance it at
the same time as the affected extremity.
22. 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.
23. Assessment begins with the nurses first
encounter with the patient and continues
throughout the patients stay. The nurse
obtains assessment data through the health
history, physical examination, and review
of diagnostic studies.
24. The appropriate needle size for insulin
injection is 25G and 5/8 long.
25. Residual urine is urine that remains in the
bladder after voiding. The amount of
residual urine is normally 50 to 100 ml.
26. The five stages of the nursing process are
assessment, nursing diagnosis, planning,
implementation, and evaluation.
27. Assessment is the stage of the nursing
process in which the nurse continuously
collects data to identify a patients actual
and potential health needs.
28. Nursing diagnosis is the stage of the
nursing process in which the nurse makes
a clinical judgment about individual,
family, or community responses to actual
or potential health problems or life
processes.
29. Planning is the stage of the nursing
process in which the nurse assigns
priorities to nursing diagnoses, defines
short-term and long-term goals and
expected outcomes, and establishes the
nursing care plan.
30. Implementation is the stage of the nursing
process in which the nurse puts the
nursing care plan into action, delegates
specific nursing interventions to members
of the nursing team, and charts patient
responses to nursing interventions.
31. Evaluation is the stage of the nursing
process in which the nurse compares
objective and subjective data with the
outcome criteria and, if needed, modifies
the nursing care plan.
32. Before administering any as needed
pain medication, the nurse should ask the
patient to indicate the location of the pain.
33. Jehovahs Witnesses believe that they
shouldnt receive blood components
donated by other people.
34. To test visual acuity, the nurse should ask
the patient to cover each eye separately
and to read the eye chart with glasses and
without, as appropriate.
35. When providing oral care for an
unconscious patient, to minimize the risk
of aspiration, the nurse should position the
patient on the side.
36. During assessment of distance vision, the
patient should stand 20 (6.1 m) from the
chart.
37. For a geriatric patient or one who is
extremely ill, the ideal room temperature
is 66 to 76 F (18.8 to 24.4 C).
38. Normal room humidity is 30% to 60%.
39. Hand washing is the single best method of
limiting the spread of microorganisms.
Once gloves are removed after routine
contact with a patient, hands should be
washed for 10 to 15 seconds.
40. To perform catheterization, the nurse
should place a woman in the dorsal
recumbent position.
41. A positive Homans sign may indicate
thrombophlebitis.
42. Electrolytes in a solution are measured in
milliequivalents per liter (mEq/L). A
milliequivalent is the number of
milligrams per 100 milliliters of a
solution.
43. Metabolism occurs in two phases:
anabolism (the constructive phase) and
catabolism (the destructive phase).
44. The basal metabolic rate is the amount of
energy needed to maintain essential body
functions. Its measured when the patient
is awake and resting, hasnt eaten for 14 to
18 hours, and is in a comfortable, warm
environment.
45. The basal metabolic rate is expressed in
calories consumed per hour per kilogram
of body weight.
46. Dietary fiber (roughage), which is derived
from cellulose, supplies bulk, maintains
intestinal motility, and helps to establish
regular bowel habits.
47. Alcohol is metabolized primarily in the
liver. Smaller amounts are metabolized by
the kidneys and lungs.
48. Petechiae are tiny, round, purplish red
spots that appear on the skin and mucous
membranes as a result of intradermal or
submucosal hemorrhage.
49. Purpura is a purple discoloration of the
skin thats caused by blood extravasation.
50. According to the standard precautions
recommended by the Centers for Disease
Control and Prevention, the nurse
shouldnt recap needles after use. Most
needle sticks result from missed needle
recapping.
51. The nurse administers a drug by I.V. push
by using a needle and syringe to deliver
the dose directly into a vein, I.V. tubing,
or a catheter.
52. When changing the ties on a tracheostomy
tube, the nurse should leave the old ties in
place until the new ones are applied.
53. A nurse should have assistance when
changing the ties on a tracheostomy tube.
54. A filter is always used for blood
transfusions.
55. A four-point (quad) cane is indicated
when a patient needs more stability than a
regular cane can provide.
56. A good way to begin a patient interview is
to ask, What made you seek medical
help?
57. When caring for any patient, the nurse
should follow standard precautions for
handling blood and body fluids.
58. Potassium (K+) is the most abundant
cation in intracellular fluid.
59. 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.
60. In the three-point gait, the patient moves
two crutches and the affected leg
simultaneously and then moves the
unaffected leg.
61. 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.
62. 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).
63. When being weighed, an adult patient
should be lightly dressed and shoeless.
64. Before taking an adults temperature
orally, the nurse should ensure that the
patient hasnt smoked or consumed hot or
cold substances in the previous 15
minutes.
65. The nurse shouldnt take an adults
temperature rectally if the patient has a
cardiac disorder, anal lesions, or bleeding
hemorrhoids or has recently undergone
rectal surgery.
66. In a patient who has a cardiac disorder,
measuring temperature rectally may
stimulate a vagal response and lead to
vasodilation and decreased cardiac output.
67. 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).
68. 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.
69. On the morning of surgery, the nurse
should ensure that the informed consent
form has been signed; that the patient
hasnt 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. Artificial limbs and
other prostheses are usually removed.
70. Comfort measures, such as positioning the
patient, rubbing the patients back, and
providing a restful environment, may
decrease the patients need for analgesics
or may enhance their effectiveness.
71. A drug has three names: generic name,
which is used in official publications;
trade, or brand, name (such as Tylenol),
which is selected by the drug company;
and chemical name, which describes the
drugs chemical composition.
72. To avoid staining the teeth, the patient
should take a liquid iron preparation
through a straw.
73. The nurse should use the Z-track method
to administer an I.M. injection of iron
dextran (Imferon).
74. An organism may enter the body through
the nose, mouth, rectum, urinary or
reproductive tract, or skin.
75. In descending order, the levels of
consciousness are alertness, lethargy,
stupor, light coma, and deep coma.
76. To turn a patient by logrolling, the nurse
folds the patients arms across the chest;
extends the patients legs and inserts a
pillow between them, if needed; places a
draw sheet under the patient; and turns the
patient by slowly and gently pulling on the
draw sheet.
77. The diaphragm of the stethoscope is used
to hear high-pitched sounds, such as
breath sounds.
78. A slight difference in blood pressure (5 to
10 mm Hg) between the right and the left
arms is normal.
79. The nurse should place the blood pressure
cuff 1 (2.5 cm) above the antecubital
fossa.
80. 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.
81. The nurse should use a leg cuff to measure
blood pressure in an obese patient.
82. If a blood pressure cuff is applied too
loosely, the reading will be falsely
lowered.
83. Ptosis is drooping of the eyelid.
84. 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.
85. To perform venipuncture with the least
injury to the vessel, the nurse should turn
the bevel upward when the vessels lumen
is larger than the needle and turn it
downward when the lumen is only slightly
larger than the needle.
86. To move a patient to the edge of the bed
for transfer, the nurse should follow these
steps: Move the patients head and
shoulders toward the edge of the bed.
Move the patients feet and legs to the
edge of the bed (crescent position). Place
both arms well under the patients hips,
and straighten the back while moving the
patient toward the edge of the bed.
87. When being measured for crutches, a
patient should wear shoes.
88. 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.
89. The mist in a mist tent should never
become so dense that it obscures clear
visualization of the patients respiratory
pattern.
90. To administer heparin subcutaneously, the
nurse should follow these steps: Clean, but
dont rub, the site with alcohol. Stretch the
skin taut or pick up a well-defined skin
fold. Hold the shaft of the needle in a dart
position. Insert the needle into the skin at
a right (90-degree) angle. Firmly depress
the plunger, but dont aspirate. Leave the
needle in place for 10 seconds. Withdraw
the needle gently at the angle of insertion.
Apply pressure to the injection site with
an alcohol pad.
91. For a sigmoidoscopy, the nurse should
place the patient in the knee-chest position
or Sims position, depending on the
physicians preference.
92. Maslows hierarchy of needs must be met
in the following order: physiologic
(oxygen, food, water, sex, rest, and
comfort), safety and security, love and
belonging, self-esteem and recognition,
and self-actualization.
93. When caring for a patient who has a
nasogastric tube, the nurse should apply a
water-soluble lubricant to the nostril to
prevent soreness.
94. During gastric lavage, a nasogastric tube
is inserted, the stomach is flushed, and
ingested substances are removed through
the tube.
95. In documenting drainage on a surgical
dressing, the nurse should include the size,
color, and consistency of the drainage (for
example, 10 mm of brown mucoid
drainage noted on dressing).
96. To elicit Babinskis reflex, the nurse
strokes the sole of the patients foot with a
moderately sharp object, such as a
thumbnail.
97. A positive Babinskis reflex is shown by
dorsiflexion of the great toe and fanning
out of the other toes.
98. When assessing a patient for bladder
distention, the nurse should check the
contour of the lower abdomen for a
rounded mass above the symphysis pubis.
99. The best way to prevent pressure ulcers is
to reposition the bedridden patient at least
every 2 hours.
100. Antiembolism stockings decompress
the superficial blood vessels, reducing the
risk of thrombus formation.
101. In adults, the most convenient veins
for venipuncture are the basilic and
median cubital veins in the antecubital
space.
102. Two to three hours before beginning a
tube feeding, the nurse should aspirate the
patients stomach contents to verify that
gastric emptying is adequate.
103. People with type O blood are
considered universal donors.
104. People with type AB blood are
considered universal recipients.
105. Hertz (Hz) is the unit of measurement
of sound frequency.
106. Hearing protection is required when
the sound intensity exceeds 84 dB. Double
hearing protection is required if it exceeds
104 dB.
107. Prothrombin, a clotting factor, is
produced in the liver.
108. If a patient is menstruating when a
urine sample is collected, the nurse should
note this on the laboratory request.
109. During lumbar puncture, the nurse
must note the initial intracranial pressure
and the color of the cerebrospinal fluid.
110. If a patient cant cough to provide a
sputum sample for culture, a heated
aerosol treatment can be used to help to
obtain a sample.
111. If eye ointment and eyedrops must be
instilled in the same eye, the eyedrops
should be instilled first.
112. When leaving an isolation room, the
nurse should remove her gloves before her
mask because fewer pathogens are on the
mask.
113. Skeletal traction, which is applied to a
bone with wire pins or tongs, is the most
effective means of traction.
114. The total parenteral nutrition solution
should be stored in a refrigerator and
removed 30 to 60 minutes before use.
Delivery of a chilled solution can cause
pain, hypothermia, venous spasm, and
venous constriction.
115. Drugs arent routinely injected
intramuscularly into edematous tissue
because they may not be absorbed.
116. When caring for a comatose patient,
the nurse should explain each action to the
patient in a normal voice.
117. Dentures should be cleaned in a sink
thats lined with a washcloth.
118. A patient should void within 8 hours
after surgery.
119. An EEG identifies normal and
abnormal brain waves.
120. Samples of feces for ova and parasite
tests should be delivered to the laboratory
without delay and without refrigeration.
121. The autonomic nervous system
regulates the cardiovascular and
respiratory systems.
122. When providing tracheostomy care,
the nurse should insert the catheter gently
into the tracheostomy tube. When
withdrawing the catheter, the nurse should
apply intermittent suction for no more
than 15 seconds and use a slight twisting
motion.
123. A low-residue diet includes such foods
as roasted chicken, rice, and pasta.
124. A rectal tube shouldnt be inserted for
longer than 20 minutes because it can
irritate the rectal mucosa and cause loss of
sphincter control.
125. A patients bed bath should proceed in
this order: face, neck, arms, hands, chest,
abdomen, back, legs, perineum.
126. To prevent injury when lifting and
moving a patient, the nurse should
primarily use the upper leg muscles.
127. Patient preparation for
cholecystography includes ingestion of a
contrast medium and a low-fat evening
meal.
128. While an occupied bed is being
changed, the patient should be covered
with a bath blanket to promote warmth
and prevent exposure.
129. Anticipatory grief is mourning that
occurs for an extended time when the
patient realizes that death is inevitable.
130. 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).
131. When preparing for a skull X-ray, the
patient should remove all jewelry and
dentures.
132. The fight-or-flight response is a
sympathetic nervous system response.
133. Bronchovesicular breath sounds in
peripheral lung fields are abnormal and
suggest pneumonia.
134. Wheezing is an abnormal, high-
pitched breath sound thats accentuated on
expiration.
135. Wax or a foreign body in the ear
should be flushed out gently by irrigation
with warm saline solution.
136. If a patient complains that his hearing
aid is not working, the nurse should
check the switch first to see if its turned
on and then check the batteries.
137. The nurse should grade hyperactive
biceps and triceps reflexes as +4.
138. If two eye medications are prescribed
for twice-daily instillation, they should be
administered 5 minutes apart.
139. In a postoperative patient, forcing
fluids helps prevent constipation.
140. A nurse must provide care in
accordance with standards of care
established by the American Nurses
Association, state regulations, and facility
policy.
141. 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.
142. As nutrients move through the body,
they undergo ingestion, digestion,
absorption, transport, cell metabolism, and
excretion.
143. The body metabolizes alcohol at a
fixed rate, regardless of serum
concentration.
144. In an alcoholic beverage, proof
reflects the percentage of alcohol
multiplied by 2. For example, a 100-proof
beverage contains 50% alcohol.
145. A living will is a witnessed document
that states a patients desire for certain
types of care and treatment. These
decisions are based on the patients wishes
and views on quality of life.
146. The nurse should flush a peripheral
heparin lock every 8 hours (if it wasnt
used during the previous 8 hours) and as
needed with normal saline solution to
maintain patency.
147. Quality assurance is a method of
determining whether nursing actions and
practices meet established standards.
148. The five rights of medication
administration are the right patient, right
drug, right dose, right route of
administration, and right time.
149. The evaluation phase of the nursing
process is to determine whether nursing
interventions have enabled the patient to
meet the desired goals.
150. Outside of the hospital setting, only
the sublingual and translingual forms of
nitroglycerin should be used to relieve
acute anginal attacks.
151. The implementation phase of the
nursing process involves recording the
patients response to the nursing plan,
putting the nursing plan into action,
delegating specific nursing interventions,
and coordinating the patients activities.
152. The Patients 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.
153. To minimize omission and distortion
of facts, the nurse should record
information as soon as its gathered.
154. When assessing a patients health
history, the nurse should record the
current illness chronologically, beginning
with the onset of the problem and
continuing to the present.
155. When assessing a patients health
history, the nurse should record the
current illness chronologically, beginning
with the onset of the problem and
continuing to the present.
156. A nurse shouldnt give false assurance
to a patient.
157. After receiving preoperative
medication, a patient isnt competent to
sign an informed consent form.
158. When lifting a patient, a nurse uses the
weight of her body instead of the strength
in her arms.
159. A nurse may clarify a physicians
explanation about an operation or a
procedure to a patient, but must refer
questions about informed consent to the
physician.
160. When obtaining a health history from
an acutely ill or agitated patient, the nurse
should limit questions to those that
provide necessary information.
161. If a chest drainage system line is
broken or interrupted, the nurse should
clamp the tube immediately.
162. The nurse shouldnt use her thumb to
take a patients pulse rate because the
thumb has a pulse that may be confused
with the patients pulse.
163. An inspiration and an expiration count
as one respiration.
164. Eupnea is normal respiration.
165. During blood pressure measurement,
the patient should rest the arm against a
surface. Using muscle strength to hold up
the arm may raise the blood pressure.
166. Major, unalterable risk factors for
coronary artery disease include heredity,
sex, race, and age.
167. Inspection is the most frequently used
assessment technique.
168. Family members of an elderly person
in a long-term care facility should transfer
some personal items (such as photographs,
a favorite chair, and knickknacks) to the
persons room to provide a comfortable
atmosphere.
169. Pulsus alternans is a regular pulse
rhythm with alternating weak and strong
beats. It occurs in ventricular enlargement
because the stroke volume varies with
each heartbeat.
170. The upper respiratory tract warms and
humidifies inspired air and plays a role in
taste, smell, and mastication.
171. Signs of accessory muscle use include
shoulder elevation, intercostal muscle
retraction, and scalene and
sternocleidomastoid muscle use during
respiration.
172. When patients use axillary crutches,
their palms should bear the brunt of the
weight.
173. Activities of daily living include
eating, bathing, dressing, grooming,
toileting, and interacting socially.
174. Normal gait has two phases: the stance
phase, in which the patients foot rests on
the ground, and the swing phase, in which
the patients foot moves forward.
175. The phases of mitosis are prophase,
metaphase, anaphase, and telophase.
176. The nurse should follow standard
precautions in the routine care of all
patients.
177. The nurse should use the bell of the
stethoscope to listen for venous hums and
cardiac murmurs.
178. The nurse can assess a patients
general knowledge by asking questions
such as Who is the president of the
United States?
179. Cold packs are applied for the first 20
to 48 hours after an injury; then heat is
applied. 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.
180. The pons is located above the medulla
and consists of white matter (sensory and
motor tracts) and gray matter (reflex
centers).
181. The autonomic nervous system
controls the smooth muscles.
182. 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. Its developed in
collaboration with the patient.
183. Percussion causes five basic notes:
tympany (loud intensity, as heard over a
gastric air bubble or puffed out cheek),
hyperresonance (very loud, as heard over
an emphysematous lung), resonance (loud,
as heard over a normal lung), dullness
(medium intensity, as heard over the liver
or other solid organ), and flatness (soft, as
heard over the thigh).
184. The optic disk is yellowish pink and
circular, with a distinct border.
185. A primary disability is caused by a
pathologic process. A secondary disability
is caused by inactivity.
186. Nurses are commonly held liable for
failing to keep an accurate count of
sponges and other devices during surgery.
187. The best dietary sources of vitamin B6
are liver, kidney, pork, soybeans, corn,
and whole-grain cereals.
188. Iron-rich foods, such as organ meats,
nuts, legumes, dried fruit, green leafy
vegetables, eggs, and whole grains,
commonly have a low water content.
189. Collaboration is joint communication
and decision making between nurses and
physicians. Its designed to meet patients
needs by integrating the care regimens of
both professions into one comprehensive
approach.
190. Bradycardia is a heart rate of fewer
than 60 beats/minute.
191. A nursing diagnosis is a statement of a
patients actual or potential health
problem that can be resolved, diminished,
or otherwise changed by nursing
interventions.
192. During the assessment phase of the
nursing process, the nurse collects and
analyzes three types of data: health
history, physical examination, and
laboratory and diagnostic test data.
193. The patients health history consists
primarily of subjective data, information
thats supplied by the patient.
194. The physical examination includes
objective data obtained by inspection,
palpation, percussion, and auscultation.
195. When documenting patient care, the
nurse should write legibly, use only
standard abbreviations, and sign each
entry. The nurse should never destroy or
attempt to obliterate documentation or
leave vacant lines.
196. Factors that affect body temperature
include time of day, age, physical activity,
phase of menstrual cycle, and pregnancy.
197. The most accessible and commonly
used artery for measuring a patients pulse
rate is the radial artery. To take the pulse
rate, the artery is compressed against the
radius.
198. In a resting adult, the normal pulse
rate is 60 to 100 beats/minute. The rate is
slightly faster in women than in men and
much faster in children than in adults.
199. Laboratory test results are an objective
form of assessment data.
200. The measurement systems most
commonly used in clinical practice are the
metric system, apothecaries system, and
household system.
201. 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. The
patient should also have a general idea of
the time required from surgery to
recovery. In addition, he should have an
opportunity to ask questions.
202. A patient must sign a separate
informed consent form for each
procedure.
203. During percussion, the nurse uses
quick, sharp tapping of the fingers or
hands against body surfaces to produce
sounds. This procedure is done to
determine the size, shape, position, and
density of underlying organs and tissues;
elicit tenderness; or assess reflexes.
204. Ballottement is a form of light
palpation involving gentle, repetitive
bouncing of tissues against the hand and
feeling their rebound.
205. A foot cradle keeps bed linen off the
patients feet to prevent skin irritation and
breakdown, especially in a patient who
has peripheral vascular disease or
neuropathy.
206. Gastric lavage is flushing of the
stomach and removal of ingested
substances through a nasogastric tube. Its
used to treat poisoning or drug overdose.
207. During the evaluation step of the
nursing process, the nurse assesses the
patients response to therapy.
208. Bruits commonly indicate life- or
limb-threatening vascular disease.
209. O.U. means each eye. O.D. is the right
eye, and O.S. is the left eye.
210. To remove a patients artificial eye,
the nurse depresses the lower lid.
211. The nurse should use a warm saline
solution to clean an artificial eye.
212. A thready pulse is very fine and
scarcely perceptible.
213. Axillary temperature is usually 1 F
lower than oral temperature.
214. After suctioning a tracheostomy tube,
the nurse must document the color,
amount, consistency, and odor of
secretions.
215. On a drug prescription, the
abbreviation p.c. means that the drug
should be administered after meals.
216. After bladder irrigation, the nurse
should document the amount, color, and
clarity of the urine and the presence of
clots or sediment.
217. After bladder irrigation, the nurse
should document the amount, color, and
clarity of the urine and the presence of
clots or sediment.
218. Laws regarding patient self-
determination vary from state to state.
Therefore, the nurse must be familiar with
the laws of the state in which she works.
219. Gauge is the inside diameter of a
needle: the smaller the gauge, the larger
the diameter.
220. An adult normally has 32 permanent
teeth.
Bullets
(FUNDAMENTAL OF
NURSING 2)
1. After turning a patient, the nurse should
document the position used, the time that the
patient was turned, and the findings of skin
assessment.
2. PERRLA is an abbreviation for normal
pupil assessment findings: pupils equal, round,
and reactive to light with accommodation.
3. When percussing a patients chest for
postural drainage, the nurses hands should be
cupped.
4. When measuring a patients pulse, the nurse
should assess its rate, rhythm, quality, and
strength.
5. Before transferring a patient from a bed to a
wheelchair, the nurse should push the
wheelchair footrests to the sides and lock its
wheels.
6. When assessing respirations, the nurse
should document their rate, rhythm, depth, and
quality.
7. For a subcutaneous injection, the nurse
should use a 5/8 25G needle.
8. The notation AA & O 3 indicates that
the patient is awake, alert, and oriented to
person (knows who he is), place (knows where
he is), and time (knows the date and time).
9. Fluid intake includes all fluids taken by
mouth, including foods that are liquid at room
temperature, such as gelatin, custard, and ice
cream; I.V. fluids; and fluids administered in
feeding tubes. Fluid output includes urine,
vomitus, and drainage (such as from a
nasogastric tube or from a wound) as well as
blood loss, diarrhea or feces, and perspiration.
10. After administering an intradermal
injection, the nurse shouldnt massage the area
because massage can irritate the site and
interfere with results.
11. When administering an intradermal
injection, the nurse should hold the syringe
almost flat against the patients skin (at about
a 15-degree angle), with the bevel up.
12. To obtain an accurate blood pressure, the
nurse should inflate the manometer to 20 to 30
mm Hg above the disappearance of the radial
pulse before releasing the cuff pressure.
13. The nurse should count an irregular pulse
for 1 full minute.
14. A patient who is vomiting while lying
down should be placed in a lateral position to
prevent aspiration of vomitus.
15. Prophylaxis is disease prevention.
16. Body alignment is achieved when body
parts are in proper relation to their natural
position.
17. Trust is the foundation of a nurse-patient
relationship.
18. Blood pressure is the force exerted by the
circulating volume of blood on the arterial
walls.
19. Malpractice is a professionals wrongful
conduct, improper discharge of duties, or
failure to meet standards of care that causes
harm to another.
20. As a general rule, nurses cant refuse a
patient care assignment; however, in most
states, they may refuse to participate in
abortions.
21. A nurse can be found negligent if a patient
is injured because the nurse failed to perform a
duty that a reasonable and prudent person
would perform or because the nurse performed
an act that a reasonable and prudent person
wouldnt perform.
22. States have enacted Good Samaritan laws
to encourage professionals to provide medical
assistance at the scene of an accident without
fear of a lawsuit arising from the assistance.
These laws dont apply to care provided in a
health care facility.
23. A physician should sign verbal and
telephone orders within the time established
by facility policy, usually 24 hours.
24. A competent adult has the right to refuse
lifesaving medical treatment; however, the
individual should be fully informed of the
consequences of his refusal.
25. Although a patients health record, or
chart, is the health care facilitys physical
property, its contents belong to the patient.
26. Before a patients health record can be
released to a third party, the patient or the
patients legal guardian must give written
consent.
27. Under the Controlled Substances Act,
every dose of a controlled drug thats
dispensed by the pharmacy must be accounted
for, whether the dose was administered to a
patient or discarded accidentally.
28. A nurse cant perform duties that violate a
rule or regulation established by a state
licensing board, even if they are authorized by
a health care facility or physician.
29. To minimize interruptions during a patient
interview, the nurse should select a private
room, preferably one with a door that can be
closed.
30. In categorizing nursing diagnoses, the
nurse addresses life-threatening problems first,
followed by potentially life-threatening
concerns.
31. The major components of a nursing care
plan are outcome criteria (patient goals) and
nursing interventions.
32. Standing orders, or protocols, establish
guidelines for treating a specific disease or set
of symptoms.
33. In assessing a patients heart, the nurse
normally finds the point of maximal impulse
at the fifth intercostal space, near the apex.
34. The S1 heard on auscultation is caused by
closure of the mitral and tricuspid valves.
35. To maintain package sterility, the nurse
should open a wrappers top flap away from
the body, open each side flap by touching only
the outer part of the wrapper, and open the
final flap by grasping the turned-down corner
and pulling it toward the body.
36. The nurse shouldnt dry a patients ear
canal or remove wax with a cotton-tipped
applicator because it may force cerumen
against the tympanic membrane.
37. A patients identification bracelet should
remain in place until the patient has been
discharged from the health care facility and
has left the premises.
38. The Controlled Substances Act designated
five categories, or schedules, that classify
controlled drugs according to their abuse
potential.
39. Schedule I drugs, such as heroin, have a
high abuse potential and have no currently
accepted medical use in the United States.
40. Schedule II drugs, such as morphine,
opium, and meperidine (Demerol), have a high
abuse potential, but currently have accepted
medical uses. Their use may lead to physical
or psychological dependence.
41. Schedule III drugs, such as paregoric and
butabarbital (Butisol), have a lower abuse
potential than Schedule I or II drugs. Abuse of
Schedule III drugs may lead to moderate or
low physical or psychological dependence, or
both.
42. Schedule IV drugs, such as chloral
hydrate, have a low abuse potential compared
with Schedule III drugs.
43. Schedule V drugs, such as cough syrups
that contain codeine, have the lowest abuse
potential of the controlled substances.
44. Activities of daily living are actions that
the patient must perform every day to provide
self-care and to interact with society.
45. Testing of the six cardinal fields of gaze
evaluates the function of all extraocular
muscles and cranial nerves III, IV, and VI.
46. The six types of heart murmurs are graded
from 1 to 6. A grade 6 heart murmur can be
heard with the stethoscope slightly raised from
the chest.
47. The most important goal to include in a
care plan is the patients goal.
48. Fruits are high in fiber and low in protein,
and should be omitted from a low-residue diet.
49. The nurse should use an objective scale to
assess and quantify pain. Postoperative pain
varies greatly among individuals.
50. Postmortem care includes cleaning and
preparing the deceased patient for family
viewing, arranging transportation to the
morgue or funeral home, and determining the
disposition of belongings.
51. The nurse should provide honest answers
to the patients questions.
52. Milk shouldnt be included in a clear
liquid diet.
53. When caring for an infant, a child, or a
confused patient, consistency in nursing
personnel is paramount.
54. The hypothalamus secretes vasopressin
and oxytocin, which are stored in the pituitary
gland.
55. The three membranes that enclose the
brain and spinal cord are the dura mater, pia
mater, and arachnoid.
56. A nasogastric tube is used to remove fluid
and gas from the small intestine preoperatively
or postoperatively.
57. Psychologists, physical therapists, and
chiropractors arent authorized to write
prescriptions for drugs.
58. The area around a stoma is cleaned with
mild soap and water.
59. Vegetables have a high fiber content.
60. The nurse should use a tuberculin syringe
to administer a subcutaneous injection of less
than 1 ml.
61. For adults, subcutaneous injections require
a 25G 1 needle; for infants, children, elderly,
or very thin patients, they require a 25G to
27G needle.
62. Before administering a drug, the nurse
should identify the patient by checking the
identification band and asking the patient to
state his name.
63. To clean the skin before an injection, the
nurse uses a sterile alcohol swab to wipe from
the center of the site outward in a circular
motion.
64. The nurse should inject heparin deep into
subcutaneous tissue at a 90-degree angle
(perpendicular to the skin) to prevent skin
irritation.
65. If blood is aspirated into the syringe before
an I.M. injection, the nurse should withdraw
the needle, prepare another syringe, and repeat
the procedure.
66. The nurse shouldnt cut the patients hair
without written consent from the patient or an
appropriate relative.
67. If bleeding occurs after an injection, the
nurse should apply pressure until the bleeding
stops. If bruising occurs, the nurse should
monitor the site for an enlarging hematoma.
68. When providing hair and scalp care, the
nurse should begin combing at the end of the
hair and work toward the head.
69. The frequency of patient hair care depends
on the length and texture of the hair, the
duration of hospitalization, and the patients
condition.
70. Proper function of a hearing aid requires
careful handling during insertion and removal,
regular cleaning of the ear piece to prevent
wax buildup, and prompt replacement of dead
batteries.
71. The hearing aid thats marked with a blue
dot is for the left ear; the one with a red dot is
for the right ear.
72. A hearing aid shouldnt be exposed to heat
or humidity and shouldnt be immersed in
water.
73. The nurse should instruct the patient to
avoid using hair spray while wearing a hearing
aid.
74. The five branches of pharmacology are
pharmacokinetics, pharmacodynamics,
pharmacotherapeutics, toxicology, and
pharmacognosy.
75. The nurse should remove heel protectors
every 8 hours to inspect the foot for signs of
skin breakdown.
76. Heat is applied to promote vasodilation,
which reduces pain caused by inflammation.
77. A sutured surgical incision is an example
of healing by first intention (healing directly,
without granulation).
78. Healing by secondary intention (healing
by granulation) is closure of the wound when
granulation tissue fills the defect and allows
reepithelialization to occur, beginning at the
wound edges and continuing to the center,
until the entire wound is covered.
79. Keloid formation is an abnormality in
healing thats characterized by overgrowth of
scar tissue at the wound site.
80. The nurse should administer procaine
penicillin by deep I.M. injection in the upper
outer portion of the buttocks in the adult or in
the midlateral thigh in the child. The nurse
shouldnt massage the injection site.
81. An ascending colostomy drains fluid feces.
A descending colostomy drains solid fecal
matter.
82. A folded towel (scrotal bridge) can
provide scrotal support for the patient with
scrotal edema caused by vasectomy,
epididymitis, or orchitis.
83. When giving an injection to a patient who
has a bleeding disorder, the nurse should use a
small-gauge needle and apply pressure to the
site for 5 minutes after the injection.
84. Platelets are the smallest and most fragile
formed element of the blood and are essential
for coagulation.
85. To insert a nasogastric tube, the nurse
instructs the patient to tilt the head back
slightly and then inserts the tube. When the
nurse feels the tube curving at the pharynx, the
nurse should tell the patient to tilt the head
forward to close the trachea and open the
esophagus by swallowing. (Sips of water can
facilitate this action.)
86. Families with loved ones in intensive care
units report that their four most important
needs are to have their questions answered
honestly, to be assured that the best possible
care is being provided, to know the patients
prognosis, and to feel that there is hope of
recovery.
87. Double-bind communication occurs when
the verbal message contradicts the nonverbal
message and the receiver is unsure of which
message to respond to.
88. A nonjudgmental attitude displayed by a
nurse shows that she neither approves nor
disapproves of the patient.
89. Target symptoms are those that the patient
finds most distressing.
90. A patient should be advised to take aspirin
on an empty stomach, with a full glass of
water, and should avoid acidic foods such as
coffee, citrus fruits, and cola.
91. For every patient problem, there is a
nursing diagnosis; for every nursing diagnosis,
there is a goal; and for every goal, there are
interventions designed to make the goal a
reality. The keys to answering examination
questions correctly are identifying the problem
presented, formulating a goal for the problem,
and selecting the intervention from the choices
provided that will enable the patient to reach
that goal.
92. Fidelity means loyalty and can be shown
as a commitment to the profession of nursing
and to the patient.
93. Administering an I.M. injection against the
patients will and without legal authority is
battery.
94. An example of a third-party payer is an
insurance company.
95. The formula for calculating the drops per
minute for an I.V. infusion is as follows:
(volume to be infused drip factor) time in
minutes = drops/minute
96. On-call medication should be given within
5 minutes of the call.
97. Usually, the best method to determine a
patients cultural or spiritual needs is to ask
him.
98. An incident report or unusual occurrence
report isnt part of a patients record, but is an
in-house document thats used for the purpose
of correcting the problem.
99. Critical pathways are a multidisciplinary
guideline for patient care.
100. When prioritizing nursing diagnoses, the
following hierarchy should be used: Problems
associated with the airway, those concerning
breathing, and those related to circulation.
101. The two nursing diagnoses that have the
highest priority that the nurse can assign are
Ineffective airway clearance and Ineffective
breathing pattern.
102. A subjective sign that a sitz bath has been
effective is the patients expression of
decreased pain or discomfort.
103. For the nursing diagnosis Deficient
diversional activity to be valid, the patient
must state that hes bored, that he has
nothing to do, or words to that effect.
104. The most appropriate nursing diagnosis
for an individual who doesnt speak English is
Impaired verbal communication related to
inability to speak dominant language
(English).
105. The family of a patient who has been
diagnosed as hearing impaired should be
instructed to face the individual when they
speak to him.
106. Before instilling medication into the ear
of a patient who is up to age 3, the nurse
should pull the pinna down and back to
straighten the eustachian tube.
107. To prevent injury to the cornea when
administering eyedrops, the nurse should
waste the first drop and instill the drug in the
lower conjunctival sac.
108. After administering eye ointment, the
nurse should twist the medication tube to
detach the ointment.
109. When the nurse removes gloves and a
mask, she should remove the gloves first.
They are soiled and are likely to contain
pathogens.
110. Crutches should be placed 6 (15.2 cm)
in front of the patient and 6 to the side to
form a tripod arrangement.
111. Listening is the most effective
communication technique.
112. Before teaching any procedure to a
patient, the nurse must assess the patients
current knowledge and willingness to learn.
113. Process recording is a method of
evaluating ones communication effectiveness.
114. When feeding an elderly patient, the
nurse should limit high-carbohydrate foods
because of the risk of glucose intolerance.
115. When feeding an elderly patient, essential
foods should be given first.
116. Passive range of motion maintains joint
mobility. Resistive exercises increase muscle
mass.
117. Isometric exercises are performed on an
extremity thats in a cast.
118. A back rub is an example of the gate-
control theory of pain.
119. Anything thats located below the waist
is considered unsterile; a 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
(2.5 cm) around a sterile field is considered
unsterile.
120. A shift to the left is evident when the
number of immature cells (bands) in the blood
increases to fight an infection.
121. A shift to the right is evident when the
number of mature cells in the blood increases,
as seen in advanced liver disease and
pernicious anemia.
122. Before administering preoperative
medication, the nurse should ensure that an
informed consent form has been signed and
attached to the patients record.
123. A nurse should spend no more than 30
minutes per 8-hour shift providing care to a
patient who has a radiation implant.
124. A nurse shouldnt be assigned to care for
more than one patient who has a radiation
implant.
125. Long-handled forceps and a lead-lined
container should be available in the room of a
patient who has a radiation implant.
126. Usually, patients who have the same
infection and are in strict isolation can share a
room.
127. Diseases that require strict isolation
include chickenpox, diphtheria, and viral
hemorrhagic fevers such as Marburg disease.
128. For the patient who abides by Jewish
custom, milk and meat shouldnt be served at
the same meal.
129. Whether the patient can perform a
procedure (psychomotor domain of learning)
is a better indicator of the effectiveness of
patient teaching than whether the patient can
simply state the steps involved in the
procedure (cognitive domain of learning).
130. According to Erik Erikson,
developmental stages are trust versus mistrust
(birth to 18 months), autonomy versus shame
and doubt (18 months to age 3), initiative
versus guilt (ages 3 to 5), industry versus
inferiority (ages 5 to 12), identity versus
identity diffusion (ages 12 to 18), intimacy
versus isolation (ages 18 to 25), generativity
versus stagnation (ages 25 to 60), and ego
integrity versus despair (older than age 60).
131. When communicating with a hearing
impaired patient, the nurse should face him.
132. An appropriate nursing intervention for
the spouse of a patient who has a serious
incapacitating disease is to help him to
mobilize a support system.
133. Hyperpyrexia is extreme elevation in
temperature above 106 F (41.1 C).
134. Milk is high in sodium and low in iron.
135. When a patient expresses concern about a
health-related issue, before addressing the
concern, the nurse should assess the patients
level of knowledge.
136. The most effective way to reduce a fever
is to administer an antipyretic, which lowers
the temperature set point.
137. When a patient is ill, its essential for the
members of his family to maintain
communication about his health needs.
138. Ethnocentrism is the universal belief that
ones way of life is superior to others.
139. When a nurse is communicating with a
patient through an interpreter, the nurse should
speak to the patient and the interpreter.
140. In accordance with the hot-cold system
used by some Mexicans, Puerto Ricans, and
other Hispanic and Latino groups, most foods,
beverages, herbs, and drugs are described as
cold.
141. Prejudice is a hostile attitude toward
individuals of a particular group.
142. Discrimination is preferential treatment
of individuals of a particular group. Its
usually discussed in a negative sense.
143. Increased gastric motility interferes with
the absorption of oral drugs.
144. The three phases of the therapeutic
relationship are orientation, working, and
termination.
145. Patients often exhibit resistive and
challenging behaviors in the orientation phase
of the therapeutic relationship.
146. Abdominal assessment is performed in
the following order: inspection, auscultation,
percussion & palpation.
147. When measuring blood pressure in a
neonate, the nurse should select a cuff thats
no less than one-half and no more than two-
thirds the length of the extremity thats used.
148. When administering a drug by Z-track,
the nurse shouldnt use the same needle that
was used to draw the drug into the syringe
because doing so could stain the skin.
149. Sites for intradermal injection include the
inner arm, the upper chest, and on the back,
under the scapula.
150. When evaluating whether an answer on
an examination is correct, the nurse should
consider whether the action thats described
promotes autonomy (independence), safety,
self-esteem, and a sense of belonging.
151. When answering a question on the
NCLEX examination, the student should
consider the cue (the stimulus for a thought)
and the inference (the thought) to determine
whether the inference is correct. When in
doubt, the nurse should select an answer that
indicates the need for further information to
eliminate ambiguity. For example, the patient
complains of chest pain (the stimulus for the
thought) and the nurse infers that the patient is
having cardiac pain (the thought). In this case,
the nurse hasnt confirmed whether the pain is
cardiac. It would be more appropriate to make
further assessments.
152. Veracity is truth and is an essential
component of a therapeutic relationship
between a health care provider and his patient.
153. Beneficence is the duty to do no harm
and the duty to do good. Theres an obligation
in patient care to do no harm and an equal
obligation to assist the patient.
154. Nonmaleficence is the duty to do no
harm.
155. Fryes ABCDE cascade provides a
framework for prioritizing care by identifying
the most important treatment concerns.
156. A = Airway. This category includes
everything that affects a patent airway,
including a foreign object, fluid from an upper
respiratory infection, and edema from trauma
or an allergic reaction.
157. B = Breathing. This category includes
everything that affects the breathing pattern,
including hyperventilation or hypoventilation
and abnormal breathing patterns, such as
Korsakoffs, Biots, or Cheyne-Stokes
respiration.
158. C = Circulation. This category includes
everything that affects the circulation,
including fluid and electrolyte disturbances
and disease processes that affect cardiac
output.
159. D = Disease processes. If the patient has
no problem with the airway, breathing, or
circulation, then the nurse should evaluate the
disease processes, giving priority to the
disease process that poses the greatest
immediate risk. For example, if a patient has
terminal cancer and hypoglycemia,
hypoglycemia is a more immediate concern.
160. E = Everything else. This category
includes such issues as writing an incident
report and completing the patient chart. When
evaluating needs, this category is never the
highest priority.
161. When answering a question on an
NCLEX examination, the basic rule is assess
before action. The student should evaluate
each possible answer carefully. Usually,
several answers reflect the implementation
phase of nursing and one or two reflect the
assessment phase. In this case, the best choice
is an assessment response unless a specific
course of action is clearly indicated.
162. Rule utilitarianism is known as the
greatest good for the greatest number of
people theory.
163. Egalitarian theory emphasizes that equal
access to goods and services must be provided
to the less fortunate by an affluent society.
164. Active euthanasia is actively helping a
person to die.
165. Brain death is irreversible cessation of all
brain function.
166. Passive euthanasia is stopping the
therapy thats sustaining life.
167. A third-party payer is an insurance
company.
168. Utilization review is performed to
determine whether the care provided to a
patient was appropriate and cost-effective.
169. A value cohort is a group of people who
experienced an out-of-the-ordinary event that
shaped their values.
170. Voluntary euthanasia is actively helping
a patient to die at the patients request.
171. Bananas, citrus fruits, and potatoes are
good sources of potassium.
172. Good sources of magnesium include fish,
nuts, and grains.
173. Beef, oysters, shrimp, scallops, spinach,
beets, and greens are good sources of iron.
174. Intrathecal injection is administering a
drug through the spine.
175. When a patient asks a question or makes
a statement thats emotionally charged, the
nurse should respond to the emotion behind
the statement or question rather than to whats
being said or asked.
176. The steps of the trajectory-nursing model
are as follows:
177. Step 1: Identifying the trajectory phase
178. Step 2: Identifying the problems and
establishing goals
179. Step 3: Establishing a plan to meet the
goals
180. Step 4: Identifying factors that facilitate
or hinder attainment of the goals
181. Step 5: Implementing interventions
182. Step 6: Evaluating the effectiveness of
the interventions
183. A Hindu patient is likely to request a
vegetarian diet.
184. Pain threshold, or pain sensation, is the
initial point at which a patient feels pain.
185. The difference between acute pain and
chronic pain is its duration.
186. Referred pain is pain thats felt at a site
other than its origin.
187. Alleviating pain by performing a back
massage is consistent with the gate control
theory.
188. Rombergs test is a test for balance or
gait.
189. Pain seems more intense at night because
the patient isnt distracted by daily activities.
190. Older patients commonly dont report
pain because of fear of treatment, lifestyle
changes, or dependency.
191. No pork or pork products are allowed in a
Muslim diet.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase
the quality of life and the number of years of
optimal health
194. Eliminate health disparities among
different segments of the population.
195. A community nurse is serving as a
patients advocate if she tells a malnourished
patient to go to a meal program at a local park.
196. If a patient isnt following his treatment
plan, the nurse should first ask why.
197. Falls are the leading cause of injury in
elderly people.
198. Primary prevention is true prevention.
Examples are immunizations, weight control,
and smoking cessation.
199. Secondary prevention is early detection.
Examples include purified protein derivative
(PPD), breast self-examination, testicular self-
examination, and chest X-ray.
200. Tertiary prevention is treatment to
prevent long-term complications.
201. A patient indicates that hes coming to
terms with having a chronic disease when he
says, Im never going to get any better.
202. On noticing religious artifacts and
literature on a patients night stand, a
culturally aware nurse would ask the patient
the meaning of the items.
203. A Mexican patient may request the
intervention of a curandero, or faith healer,
who involves the family in healing the patient.
204. In an infant, the normal hemoglobin
value is 12 g/dl.
205. The nitrogen balance estimates the
difference between the intake and use of
protein.
206. Most of the absorption of water occurs in
the large intestine.
207. Most nutrients are absorbed in the small
intestine.
208. When assessing a patients eating habits,
the nurse should ask, What have you eaten in
the last 24 hours?
209. A vegan diet should include an abundant
supply of fiber.
210. A hypotonic enema softens the feces,
distends the colon, and stimulates peristalsis.
211. First-morning urine provides the best
sample to measure glucose, ketone, pH, and
specific gravity values.
212. To induce sleep, the first step is to
minimize environmental stimuli.
213. Before moving a patient, the nurse should
assess the patients physical abilities and
ability to understand instructions as well as the
amount of strength required to move the
patient.
214. To lose 1 lb (0.5 kg) in 1 week, the
patient must decrease his weekly intake by
3,500 calories (approximately 500 calories
daily). To lose 2 lb (1 kg) in 1 week, the
patient must decrease his weekly caloric
intake by 7,000 calories (approximately 1,000
calories daily).
215. To avoid shearing force injury, a patient
who is completely immobile is lifted on a
sheet.
216. To insert a catheter from the nose
through the trachea for suction, the nurse
should ask the patient to swallow.
217. Vitamin C is needed for collagen
production.
218. Only the patient can describe his pain
accurately.
219. Cutaneous stimulation creates the release
of endorphins that block the transmission of
pain stimuli.
220. Patient-controlled analgesia is a safe
method to relieve acute pain caused by
surgical incision, traumatic injury, labor and
delivery, or cancer.
221. An Asian American or European
American typically places distance between
himself and others when communicating.
222. The patient who believes in a scientific,
or biomedical, approach to health is likely to
expect a drug, treatment, or surgery to cure
illness.
223. Chronic illnesses occur in very young as
well as middle-aged and very old people.
224. The trajectory framework for chronic
illness states that preferences about daily life
activities affect treatment decisions.
225. Exacerbations of chronic disease usually
cause the patient to seek treatment and may
lead to hospitalization.
226. School health programs provide cost-
effective health care for low-income families
and those who have no health insurance.
227. Collegiality is the promotion of
collaboration, development, and
interdependence among members of a
profession.
228. A change agent is an individual who
recognizes a need for change or is selected to
make a change within an established entity,
such as a hospital.
229. The patients bill of rights was introduced
by the American Hospital Association.
230. Abandonment is premature termination
of treatment without the patients permission
and without appropriate relief of symptoms.
231. Values clarification is a process that
individuals use to prioritize their personal
values.
232. Distributive justice is a principle that
promotes equal treatment for all.
233. Milk and milk products, poultry, grains,
and fish are good sources of phosphate.
234. The best way to prevent falls at night in
an oriented, but restless, elderly patient is to
raise the side rails.
235. By the end of the orientation phase, the
patient should begin to trust the nurse.
236. Falls in the elderly are likely to be caused
by poor vision.
237. Barriers to communication include
language deficits, sensory deficits, cognitive
impairments, structural deficits, and paralysis.
238. The three elements that are necessary for
a fire are heat, oxygen, and combustible
material.
239. Sebaceous glands lubricate the skin.
240. To check for petechiae in a dark-skinned
patient, the nurse should assess the oral
mucosa.
241. To put on a sterile glove, the nurse
should pick up the first glove at the folded
border and adjust the fingers when both gloves
are on.
242. To increase patient comfort, the nurse
should let the alcohol dry before giving an
intramuscular injection.
243. Treatment for a stage 1 ulcer on the heels
includes heel protectors.
244. Seventh-Day Adventists are usually
vegetarians.
245. Endorphins are morphine-like substances
that produce a feeling of well-being.
246. Pain tolerance is the maximum amount
and duration of pain that an individual is
willing to endure.
Bullets (MEDICAL
SURGICAL)
1. Bone scan is done by injecting
radioisotope per IV & X-rays are taken.
2. To prevent edema edema on the site of
sprain, apply cold compress on the area
for the 1st 24 hrs
3. To turn the client after lumbar
Laminectomy, use logrolling technique
4. Carpal tunnel syndrome occurs due to the
injury of median nerve.
5. Massaging the back of the head is
specifically important for the client w/
Crutchfield tong.
6. A 1 yr old child has a fracture of the L
femur. He is placed in Bryants traction.
The reason for elevation of his both legs at
90 deg. angle is his weight isnt adequate
to provide sufficient countertraction, so
his entire body must be used.
7. Swing-through crutch gait is done by
advancing both crutches together & the
client moves both legs past the level of the
crutches.
8. 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.
9. Pain on non-use of joints, subcutaneous
nodules & elevated ESR are characteristic
manifestations of rheumatoid arthritis.
10. Teaching program of a patient w/ SLE
should include emphasis on walking in
shaded area.
11. Otosclerosis is characterized by
replacement of normal bones by spongy &
highly vascularized bones.
12. Use of high pitched voice is inappropriate
for the client w/ hearing impairment.
13. Rinnes test compares air conduction w/
bone conduction.
14. Vertigo is the most characteristic
manifestation of Menieres disease.
15. Low sodium is the diet for a client w/
Menieres disease.
16. A client who had cataract surgery should
be told to call his MD if he has eye pain.
17. Risk for Injury takes priority for a client
w/ Menieres disease.
18. Irrigate the eye w/ sterile saline is the
priority nursing intervention when the
client has a foreign body protruding from
the eye.
19. Snellens Test assesses visual acuity.
20. Presbyopia is an eye disorder
characterized by lessening of the effective
powers of accommodation.
21. The primary problem in cataract is
blurring of vision.
22. The primary reason for performing
iridectomy after cataract extraction is to
prevent secondary glaucoma.
23. In acute glaucoma, the obstruction of the
flow of aqueous humor is caused by
displacement of the iris.
24. Glaucoma is characterized by irreversible
blindness.
25. Hyperopia is corrected by convex lens.
26. Pterygium is caused primarily by exposure
to dust.
27. A sterile chronic granulomatous
inflammation of the meibomian gland is
chalazion.
28. The surgical procedure w/c involves
removal of the eyeball is enucleation.
29. Snellens Test assesses visual acuity.
30. Presbyopia is an eye disorder
characterized by lessening of the effective
powers of accommodation.
31. The primary problem in cataract is
blurring of vision.
32. The primary reason for performing
iridectomy after cataract extraction is to
prevent secondary glaucoma.
33. In acute glaucoma, the obstruction of the
flow of aqueous humor is caused by
displacement of the iris.
34. Glaucoma is characterized by irreversible
blindness.
35. Hyperopia is corrected by convex lens.
36. Pterygium is caused primarily by exposure
to dust.
37. A sterile chronic granulomatous
inflammation of the meibomian gland is
chalazion.
38. The surgical procedure w/c involves
removal of the eyeball is enucleation.
39. The client is for EEG this morning.
Prepare him for the procedure by
rendering hair shampoo, excluding
caffeine from his meal & instructing the
client to remain still during the procedure.
40. If the client w/ increased ICP
demonstrates decorticate posturing,
observe for flexion of elbows, extension
of the knees, plantar flexion of the feet,
41. 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.
42. The initial nursing actionfor a client
who is in the clonic phase of a tonic-
clonic seizureis to obtain equipment for
orotracheal suctioning.
43. The first nursing intervention in a
quadriplegic client who is experiencing
autonomic dysreflexia is to elevate his
head as high as possible.
44. Following surgery for a brain tumor near
the hypothalamus, the nursing assessment
should include observing for inability to
regulate body temp.
45. Post-myelogram (using metrizamide
(Amipaque) care includes keeping head
elevated for at least 8 hrs.
46. 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.
47. Ticlopidine may be prescribed to prevent
thromboembolic CVA.
48. To maintain airway patency during a
stroke in evolution, have orotracheal
suction available at all times.
49. For a client w/ CVA, the gag reflex must
return before the client is fed.
50. Clear fluids draining from the nose of a
client who had a head trauma 3 hrs ago
may indicate basilar skull fracture.
51. An adverse effect of gingival hyperplasia
may occur during Phenytoin (DIlantin)
therapy.
52. Urine output increased: best shows that
the mannitol is effective in a client w/
increased ICP.
53. A client w/ C6 spinal injury would most
likely have the symptom of quadriplegia.
54. Falls are the leading cause of injury in
elderly people.
55. Primary prevention is true prevention.
Examples are immunizations, weight
control, and smoking cessation.
56. Secondary prevention is early detection.
Examples include purified protein
derivative (PPD), breast self-examination,
testicular self-examination, and chest X-
ray.
57. Tertiary prevention is treatment to prevent
long-term complications.
58. A patient indicates that hes coming to
terms with having a chronic disease when
he says, Im never going to get any
better.
59. On noticing religious artifacts and
literature on a patients night stand, a
culturally aware nurse would ask the
patient the meaning of the items.
60. A Mexican patient may request the
intervention of a curandero, or faith
healer, who involves the family in healing
the patient.
61. In an infant, the normal hemoglobin value
is 12 g/dl.
62. The nitrogen balance estimates the
difference between the intake and use of
protein.
63. Most of the absorption of water occurs in
the large intestine.
64. Most nutrients are absorbed in the small
intestine.
65. When assessing a patients eating habits,
the nurse should ask, What have you
eaten in the last 24 hours?
66. A vegan diet should include an abundant
supply of fiber.
67. A hypotonic enema softens the feces,
distends the colon, and stimulates
peristalsis.
68. First-morning urine provides the best
sample to measure glucose, ketone, pH,
and specific gravity values.
69. To induce sleep, the first step is to
minimize environmental stimuli.
70. Before moving a patient, the nurse should
assess the patientsv physical abilities and
ability to understand instructions as well
as the amount of strength required to
move the patient.
71. To lose 1 lb (0.5 kg) in 1 week, the patient
must decrease his weeklyv intake by 3,500
calories (approximately 500 calories
daily). To lose 2 lb (1 kg) in 1 week, the
patient must decrease his weekly caloric
intake by 7,000 calories (approximately
1,000 calories daily).
72. To avoid shearing force injury, a patient
who is completely immobile is lifted on a
sheet.
73. To insert a catheter from the nose through
the trachea for suction, the nurse should
ask the patient to swallow.
74. Vitamin C is needed for collagen
production.
75. Only the patient can describe his pain
accurately.
76. Cutaneous stimulation creates the release
of endorphins that block the transmission
of pain stimuli.
77. Patient-controlled analgesia is a safe
method to relieve acute painv caused by
surgical incision, traumatic injury, labor
and delivery, or cancer.
78. An Asian American or European
American typically places distance
between himself and others when
communicating.
79. Active euthanasia is actively helping a
person to die.
80. Brain death is irreversible cessation of all
brain function.
81. Passive euthanasia is stopping the therapy
thats sustaining life.
82. A third-party payer is an insurance
company.
83. Utilization review is performed to
determine whether the care provided to a
patient was appropriate and cost-effective.
84. A value cohort is a group of people who
experienced an out-of-the-ordinary event
that shaped their values.
85. Voluntary euthanasia is actively helping a
patient to die at the patients request.
86. Bananas, citrus fruits, and potatoes are
good sources of potassium.
87. Good sources of magnesium include fish,
nuts, and grains.
88. Beef, oysters, shrimp, scallops, spinach,
beets, and greens are good sources of iron.
89. Intrathecal injection is administering a
drug through the spine.
90. When a patient asks a question or makes a
statement thatsv emotionally charged, the
nurse should respond to the emotion
behind the statement or question rather
than to whats being said or asked.
91. The steps of the trajectory-nursing model
are as follows:
92. Step 1: Identifying the trajectory phase
93. Step 2: Identifying the problems and
establishing goals
94. Step 3: Establishing a plan to meet the
goals
95. Step 4: Identifying factors that facilitate
or hinder attainment of the goals
96. Step 5: Implementing interventions
97. Step 6: Evaluating the effectiveness of
the interventions
98. A Hindu patient is likely to request a
vegetarian diet.
99. Pain threshold, or pain sensation, is the
initial point at which a patient feels pain.
100. The difference between acute pain and
chronic pain is its duration.
101. Referred pain is pain thats felt at a
site other than its origin.
102. Alleviating pain by performing a back
massage is consistent with the gate control
theory.
103. Rombergs test is a test for balance or
gait.
104. Pain seems more intense at night
because the patient isnt distracted by
daily activities.
105. Older patients commonly dont report
pain because of fear of treatment, lifestyle
changes, or dependency.
106. No pork or pork products are allowed
in a Muslim diet.
107. Two goals of Healthy People 2010
are:
108. Help individuals of all ages to
increase the quality of life and the number
of years of optimal health
109. Eliminate health disparities among
different segments of the population.
110. A community nurse is serving as a
patients advocate if she tells av
malnourished patient to go to a meal
program at a local park.
111. If a patient isnt following his
treatment plan, the nurse should first ask
why.
112. When a patient is ill, its essential for
the members of his family to maintain
communication about his health needs.
113. Ethnocentrism is the universal belief
that ones way of life is superior to
others.
114. When a nurse is communicating with a
patient through an interpreter,v the nurse
should speak to the patient and the
interpreter.
115. 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.
116. Prejudice is a hostile attitude toward
individuals of a particular group.
117. Discrimination is preferential
treatment of individuals of a particular
group. Its usually discussed in a negative
sense.
118. Increased gastric motility interferes
with the absorption of oral drugs.
119. The three phases of the therapeutic
relationship are orientation, working, and
termination.
120. Patients often exhibit resistive and
challenging behaviors in the orientation
phase of the therapeutic relationship.
121. Abdominal assessment is performed in
the following order: inspection,
auscultation, palpation, and percussion.
122. When measuring blood pressure in a
neonate, the nurse should select a cuff
thats no less than one-half and no more
than two-thirds the length of the extremity
thats used.
123. When administering a drug by Z-track,
the nurse shouldnt use thev same needle
that was used to draw the drug into the
syringe because doing so could stain the
skin.
124. Sites for intradermal injection include
the inner arm, the upper chest, and on the
back, under the scapula.
125. When evaluating whether an answer
on an examination is correct, thev nurse
should consider whether the action thats
described promotes autonomy
(independence), safety, self-esteem, and a
sense of belonging.
126. Veracity is truth and is an essential
component of a therapeutic relationship
between a health care provider and his
patient.
127. Beneficence is the duty to do no harm
and the duty to do good.v Theres an
obligation in patient care to do no harm
and an equal obligation to assist the
patient.
128. Nonmaleficence is the duty to do no
harm.
129. Fryes ABCDE cascade provides a
framework for prioritizing care by
identifying the most important treatment
concerns.
130. A = Airway. This category includes
everything that affects a patentv airway,
including a foreign object, fluid from an
upper respiratory infection, and edema
from trauma or an allergic reaction.
131. B = Breathing. This category includes
everything that affects thev breathing
pattern, including hyperventilation or
hypoventilation and abnormal breathing
patterns, such as Korsakoffs, Biots, or
Cheyne-Stokes respiration.
132. C = Circulation. This category
includes everything that affects thev
circulation, including fluid and electrolyte
disturbances and disease processes that
affect cardiac output.
133. D = Disease processes. If the patient
has no problem with the airway,v
breathing, or circulation, then the nurse
should evaluate the disease processes,
giving priority to the disease process that
poses the greatest immediate risk. For
example, if a patient has terminal cancer
and hypoglycemia, hypoglycemia is a
more immediate concern.
134. E = Everything else. This category
includes such issues as writing anv
incident report and completing the patient
chart. When evaluating needs, this
category is never the highest priority.
135. Rule utilitarianism is known as the
greatest good for the greatest number of
people theory.
136. Egalitarian theory emphasizes that
equal access to goods and servicesv must
be provided to the less fortunate by an
affluent society.
137. Before teaching any procedure to a
patient, the nurse must assess the patients
current knowledge and willingness to
learn.
138. Process recording is a method of
evaluating ones communication
effectiveness.
139. When feeding an elderly patient, the
nurse should limit high-carbohydrate
foods because of the risk of glucose
intolerance.
140. When feeding an elderly patient,
essential foods should be given first.
141. Passive range of motion maintains
joint mobility. Resistive exercises increase
muscle mass.
142. Isometric exercises are performed on
an extremity thats in a cast.
143. A back rub is an example of the gate-
control theory of pain.
144. Anything thats 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 (2.5 cm) around a sterile
field is considered unsterile.
145. A shift to the left is evident when
the number of immature cells (bands) in
the blood increases to fight an infection.
146. A shift to the right is evident when
the number of mature cells inv the blood
increases, as seen in advanced liver
disease and pernicious anemia.
147. Before administering preoperative
medication, the nurse should ensurev that
an informed consent form has been signed
and attached to the patients record.
148. A nurse should spend no more than 30
minutes per 8-hour shift providing care to
a patient who has a radiation implant.
149. A nurse shouldnt be assigned to care
for more than one patient who has a
radiation implant.
150. Long-handled forceps and a lead-lined
container should be available in the room
of a patient who has a radiation implant.
151. Usually, patients who have the same
infection and are in strict isolation can
share a room.
152. Diseases that require strict isolation
include chickenpox, diphtheria, and viral
hemorrhagic fevers such as Marburg
disease.
153. For the patient who abides by Jewish
custom, milk and meat shouldnt be
served at the same meal.
154. Whether the patient can perform a
procedure (psychomotor domain ofv
learning) is a better indicator of the
effectiveness of patient teaching than
whether the patient can simply state the
steps involved in the procedure (cognitive
domain of learning).
155. According to Erik Erikson,
developmental stages are trust versusv
mistrust (birth to 18 months), autonomy
versus shame and doubt (18 months to age
3), initiative versus guilt (ages 3 to 5),
industry versus inferiority (ages 5 to 12),
identity versus identity diffusion (ages 12
to 18), intimacy versus isolation (ages 18
to 25), generativity versus stagnation
(ages 25 to 60), and ego integrity versus
despair (older than age 60).
156. When communicating with a hearing
impaired patient, the nurse should face
him.
157. An appropriate nursing intervention
for the spouse of a patient who has a
serious incapacitating disease is to help
him to mobilize a support system.
158. Milk is high in sodium and low in
iron.
159. When a patient expresses concern
about a health-related issue, before
addressing the concern, the nurse should
assess the patients level of knowledge.
160. The most effective way to reduce a
fever is to administer an antipyretic, which
lowers the temperature set point.
Bullets (PSYCHIATRIC)
161. According to Kbler-Ross, the
five stages of death and dying are
denial, anger, bargaining, depression,
and acceptance.
162. Flight of ideas is an alteration
in thought processes thats
characterized by skipping from one
topic to another, unrelated topic.
163. La belle indiffrence 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.
164. Moderate anxiety decreases a
persons ability to perceive and
concentrate. The person is selectively
inattentive (focuses on immediate
concerns), and the perceptual field
narrows.
165. A patient who has a phobic
disorder uses self-protective avoidance
as an ego defense mechanism.
166. In a patient who has anorexia
nervosa, the highest treatment priority
is correction of nutritional and
electrolyte imbalances.
167. A patient who is taking lithium
must undergo regular (usually once a
month) monitoring of the blood
lithium level because the margin
between therapeutic and toxic levels is
narrow. A normal laboratory value is
0.5 to 1.5 mEq/L.
168. Early signs and symptoms of
alcohol withdrawal include anxiety,
anorexia, tremors, and insomnia. They
may begin up to 8 hours after the last
alcohol intake.
169. Al-Anon is a support group for
families of alcoholics.
170. The nurse shouldnt administer
chlorpromazine (Thorazine) to a
patient who has ingested alcohol
because it may cause oversedation and
respiratory depression.
171. Lithium toxicity can occur
when sodium and fluid intake are
insufficient, causing lithium retention.
172. An alcoholic who achieves
sobriety is called a recovering
alcoholic because no cure for
alcoholism exists.
173. According to Erikson, the
school-age child (ages 6 to 12) is in
the industry-versus-inferiority stage of
psychosocial development.
174. When caring for a depressed
patient, the nurses first priority is
safety because of the increased risk of
suicide.
175. Echolalia is parrotlike
repetition of another persons words or
phrases.
176. According to psychoanalytic
theory, the ego is the part of the
psyche that controls internal demands
and interacts with the outside world at
the conscious, preconscious, and
unconscious levels.
177. According to psychoanalytic
theory, the superego is the part of the
psyche thats composed of morals,
values, and ethics. It continually
evaluates thoughts and actions,
rewarding the good and punishing the
bad. (Think of the superego as the
supercop of the unconscious.)
178. According to psychoanalytic
theory, the id is the part of the psyche
that contains instinctual drives.
(Remember i for instinctual and d for
drive.)
179. Denial is the defense
mechanism used by a patient who
denies the reality of an event.
180. 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.
Its used for patients who dont
respond to less restrictive
interventions. Seclusion controls
external behavior until the patient can
assume self-control and helps the
patient to regain self-control.
181. 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.
182. A patient who takes a
monoamine oxidase inhibitor should
be weighed biweekly and monitored
for suicidal tendencies.
183. 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.
184. Common causes of child abuse
are poor impulse control by the
parents and the lack of knowledge of
growth and development.
185. The diagnosis of Alzheimers
disease is based on clinical findings of
two or more cognitive deficits,
progressive worsening of memory, and
the results of a neuropsychological
test.
186. Memory disturbance is a
classic sign of Alzheimers disease.
187. Thought blocking is loss of the
train of thought because of a defect in
mental processing.
188. 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.
189. 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.
190. The therapeutic serum level
for lithium is 0.5 to 1.5 mEq/L.
191. Phobic disorders are treated
with desensitization therapy, which
gradually exposes a patient to an
anxiety-producing stimulus.
192. Dysfunctional grieving is
absent or prolonged grief.
193. 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.
194. 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.
195. 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.
196. 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.
197. According to Erikson, the
identity-versus-role confusion stage
occurs between ages 12 and 20.
198. Tolerance is the need for
increasing amounts of a substance to
achieve an effect that formerly was
achieved with lesser amounts.
199. Suicide is the third leading
cause of death among white teenagers.
200. Most teenagers who kill
themselves made a previous suicide
attempt and left telltale signs of their
plans.
201. In Eriksons 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.
202. Alcoholics Anonymous
recommends a 12-step program to
achieve sobriety.
203. Signs and symptoms of
anorexia nervosa include amenorrhea,
excessive weight loss, lanugo (fine
body hair), abdominal distention, and
electrolyte disturbances.
204. A serum lithium level that
exceeds 2.0 mEq/L is considered
toxic.
205. Public Law 94-247 (Child
Abuse and Neglect Act of 1973)
requires reporting of suspected cases
of child abuse to child protection
services.
206. The nurse should suspect
sexual abuse in a young child who has
blood in the feces or urine, penile or
vaginal discharge, genital trauma that
isnt readily explained, or a sexually
transmitted disease.
207. An alcoholic uses alcohol to
cope with the stresses of life.
208. The human personality
operates on three levels: conscious,
preconscious, and unconscious.
209. Asking a patient an open-
ended question is one of the best ways
to elicit or clarify information.
210. The diagnosis of autism is
often made when a child is between
ages 2 and 3.
211. Defense mechanisms protect
the personality by reducing stress and
anxiety.
212. Suppression is voluntary
exclusion of stress-producing thoughts
from the consciousness.
213. In psychodrama, life situations
are approximated in a structured
environment, allowing the participant
to recreate and enact scenes to gain
insight and to practice new skills.
214. Psychodrama is a therapeutic
technique thats used with groups to
help participants gain new perception
and self-awareness by acting out their
own or assigned problems.
215. A patient who is taking
disulfiram (Antabuse) must avoid
ingesting products that contain
alcohol, such as cough syrup,
fruitcake, and sauces and soups made
with cooking wine.
216. A patient who is admitted to a
psychiatric hospital involuntarily loses
the right to sign out against medical
advice.
217. People who live in glass
houses shouldnt throw stones and A
rolling stone gathers no moss are
examples of proverbs used during a
psychiatric interview to determine a
patients ability to think abstractly.
(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.)
218. Signs of lithium toxicity
include diarrhea, tremors, nausea,
muscle weakness, ataxia, and
confusion.
219. A labile affect is characterized
by rapid shifts of emotions and mood.
220. Amnesia is loss of memory
from an organic or inorganic cause.
221. 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.
222. Disulfiram (Antabuse)
shouldnt be taken concurrently with
metronidazole (Flagyl) because they
may interact and cause a psychotic
reaction.
223. In rare cases,
electroconvulsive therapy causes
arrhythmias and death.
224. A patient who is scheduled for
electroconvulsive therapy should
receive nothing by mouth after
midnight to prevent aspiration while
under anesthesia.
225. Electroconvulsive therapy is
normally used for patients who have
severe depression that doesnt respond
to drug therapy.
226. For electroconvulsive therapy
to be effective, the patient usually
receives 6 to 12 treatments at a rate of
2 to 3 per week.
227. 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.
228. For a patient with Alzheimers
disease, the nursing care plan should
focus on safety measures.
229. After sexual assault, the
patients needs are the primary
concern, followed by medicolegal
considerations.
230. 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.
231. Stress management is a short-
range goal of psychotherapy.
232. The mood most often
experienced by a patient with organic
brain syndrome is irritability.
233. Creative intuition is controlled
by the right side of the brain.
234. Methohexital (Brevital) is the
general anesthetic thats administered
to patients who are scheduled for
electroconvulsive therapy.
235. The decision to use restraints
should be based on the patients safety
needs.
236. Diphenhydramine (Benadryl)
relieves the extrapyramidal adverse
effects of psychotropic drugs.
237. 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. Levels should be checked
weekly to monthly during
maintenance therapy.
238. The primary purpose of
psychotropic drugs is to decrease the
patients symptoms, which improves
function and increases compliance
with therapy.
239. Manipulation is a maladaptive
method of meeting ones needs
because it disregards the needs and
feelings of others.
240. If a patient has symptoms of
lithium toxicity, the nurse should
withhold one dose and call the
physician.
241. A patient who is taking lithium
(Eskalith) for bipolar affective
disorder must maintain a balanced diet
with adequate salt intake.
242. A patient who constantly seeks
approval or assistance from staff
members and other patients is
demonstrating dependent behavior.
243. Alcoholics Anonymous
advocates total abstinence from
alcohol.
244. Methylphenidate (Ritalin) is
the drug of choice for treating
attention deficit hyperactivity disorder
in children.
245. Setting limits is the most
effective way to control manipulative
behavior.
246. Violent outbursts are common
in a patient who has borderline
personality disorder.
247. When working with a
depressed patient, the nurse should
explore meaningful losses.
248. An illusion is a
misinterpretation of an actual
environmental stimulus.
249. Anxiety is nonspecific; fear is
specific.
250. Extrapyramidal adverse effects
are common in patients who take
antipsychotic drugs.
251. The nurse should encourage an
angry patient to follow a physical
exercise program as one of the ways to
ventilate feelings.
252. Depression is clinically
significant if its characterized by
exaggerated feelings of sadness,
melancholy, dejection, worthlessness,
and hopelessness that are
inappropriate or out of proportion to
reality.
253. Free-floating anxiety is
anxiousness with generalized
apprehension and pessimism for
unknown reasons.
254. In a patient who is
experiencing intense anxiety, the fight-
or-flight reaction (alarm reflex) may
take over.
255. Confabulation is the use of
imaginary experiences or made-up
information to fill missing gaps of
memory.
256. When starting a therapeutic
relationship with a patient, the nurse
should explain that the purpose of the
therapy is to produce a positive
change.
257. A basic assumption of
psychoanalytic theory is that all
behavior has meaning.
258. Catharsis is the expression of
deep feelings and emotions.
259. According to the pleasure
principle, the psyche seeks pleasure
and avoids unpleasant experiences,
regardless of the consequences.
260. A patient who has a
conversion disorder resolves a
psychological conflict through the loss
of a specific physical function (for
example, paralysis, blindness, or
inability to swallow). This loss of
function is involuntary, but diagnostic
tests show no organic cause.
261. Chlordiazepoxide (Librium) is
the drug of choice for treating alcohol
withdrawal symptoms.
262. 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 patients condition
becomes unstable).
263. Alcohol detoxification is most
successful when carried out in a
structured environment by a
supportive, nonjudgmental staff.
264. 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.
265. The therapeutic regimen for an
alcoholic patient includes folic acid,
thiamine, and multivitamin
supplements as well as adequate food
and fluids.
266. 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. The most severe symptoms
occur within 48 hours and decrease
over the next 2 weeks.
267. Reactive depression is a
response to a specific life event.
268. Projection is the unconscious
assigning of a thought, feeling, or
action to someone or something else.
269. Sublimation is the channeling
of unacceptable impulses into socially
acceptable behavior.
270. Repression is an unconscious
defense mechanism whereby
unacceptable or painful thoughts,
impulses, memories, or feelings are
pushed from the consciousness or
forgotten.
271. Hypochondriasis is morbid
anxiety about ones health associated
with various symptoms that arent
caused by organic disease.
272. Denial is a refusal to
acknowledge feelings, thoughts,
desires, impulses, or external facts that
are consciously intolerable.
273. Reaction formation is the
avoidance of anxiety through behavior
and attitudes that are the opposite of
repressed impulses and drives.
274. Displacement is the transfer of
unacceptable feelings to a more
acceptable object.
275. Regression is a retreat to an
earlier developmental stage.
276. According to Erikson, an older
adult (age 65 or older) is in the
developmental stage of integrity
versus despair.
277. Family therapy focuses on the
family as a whole rather than the
individual. Its major objective is to
reestablish rational communication
between family members.
278. 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.
279. Ritualism and negativism are
typical toddler behaviors. They occur
during the developmental stage
identified by Erikson as autonomy
versus shame and doubt.
280. Circumstantiality is a
disturbance in associated thought and
speech patterns in which a patient
gives unnecessary, minute details and
digresses into inappropriate thoughts
that delay communication of central
ideas and goal achievement.
281. Idea of reference is an
incorrect belief that the statements or
actions of others are related to oneself.
282. Group therapy provides an
opportunity for each group member to
examine interactions, learn and
practice successful interpersonal
communication skills, and explore
emotional conflicts.
283. Korsakoffs syndrome is
believed to be a chronic form of
Wernickes encephalopathy. Its
marked by hallucinations,
confabulation, amnesia, and
disturbances of orientation.
284. A patient with antisocial
personality disorder often engages in
confrontations with authority figures,
such as police, parents, and school
officials.
285. A patient with paranoid
personality disorder exhibits
suspicion, hypervigilance, and
hostility toward others.
286. Depression is the most
common psychiatric disorder.
287. Adverse reactions to tricyclic
antidepressant drugs include
tachycardia, orthostatic hypotension,
hypomania, lowered seizure threshold,
tremors, weight gain, problems with
erections or orgasms, and anxiety.
288. The Minnesota Multiphasic
Personality Inventory consists of 550
statements for the subject to interpret.
It assesses personality and detects
disorders, such as depression and
schizophrenia, in adolescents and
adults.
289. Organic brain syndrome is the
most common form of mental illness
in elderly patients.
290. A person who has an IQ of
less than 20 is profoundly retarded and
is considered a total-care patient.
291. Reframing is a therapeutic
technique thats used to help depressed
patients to view a situation in
alternative ways.
292. Fluoxetine (Prozac), sertraline
(Zoloft), and paroxetine (Paxil) are
serotonin reuptake inhibitors used to
treat depression.
293. The early stage of Alzheimers
disease lasts 2 to 4 years. Patients have
inappropriate affect, transient
paranoia, disorientation to time,
memory loss, careless dressing, and
impaired judgment.
294. The middle stage of
Alzheimers 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.
295. The last stage of Alzheimers
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.
296. Threatening a patient with an
injection for failing to take an oral
drug is an example of assault.
297. Reexamination of life goals is
a major developmental task during
middle adulthood.
298. Acute alcohol withdrawal
causes anorexia, insomnia, headache,
and restlessness and escalates to a
syndrome thats characterized by
agitation, disorientation, vivid
hallucinations, and tremors of the
hands, feet, legs, and tongue.
299. In a hospitalized alcoholic,
alcohol withdrawal delirium most
commonly occurs 3 to 4 days after
admission.
300. Confrontation is a
communication technique in which the
nurse points out discrepancies between
the patients words and his nonverbal
behaviors.
301. 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.
302. Treatment for alcohol
withdrawal may include
administration of I.V. glucose for
hypoglycemia, I.V. fluid containing
thiamine and other B vitamins, and
antianxiety, antidiarrheal,
anticonvulsant, and antiemetic drugs.
303. The alcoholic patient receives
thiamine to help prevent peripheral
neuropathy and Korsakoffs
syndrome.
304. Alcohol withdrawal may
precipitate seizure activity because
alcohol lowers the seizure threshold in
some people.
305. Paraphrasing is an active
listening technique in which the nurse
restates what the patient has just said.
306. A patient with Korsakoffs
syndrome may use confabulation
(made up information) to cover
memory lapses or periods of amnesia.
307. People with obsessive-
compulsive disorder realize that their
behavior is unreasonable, but are
powerless to control it.
308. When witnessing psychiatric
patients who are engaged in a
threatening confrontation, the nurse
should first separate the two
individuals.
309. Patients with anorexia nervosa
or bulimia must be observed during
meals and for some time afterward to
ensure that they dont purge what they
have eaten.
310. Transsexuals believe that they
were born the wrong gender and may
seek hormonal or surgical treatment to
change their gender.
311. Fugue is a dissociative state in
which a person leaves his familiar
surroundings, assumes a new identity,
and has amnesia about his previous
identity. (Its also described as flight
from himself.)
312. In a psychiatric setting, the
patient should be able to predict the
nurses behavior and expect consistent
positive attitudes and approaches.
313. When establishing a schedule
for a one-to-one interaction with a
patient, the nurse should state how
long the conversation will last and
then adhere to the time limit.
314. Thought broadcasting is a type
of delusion in which the person
believes that his thoughts are being
broadcast for the world to hear.
315. Lithium should be taken with
food. A patient who is taking lithium
shouldnt restrict his sodium intake.
316. A patient who is taking lithium
should stop taking the drug and call
his physician if he experiences
vomiting, drowsiness, or muscle
weakness.
317. The patient who is taking a
monoamine oxidase inhibitor for
depression can include cottage cheese,
cream cheese, yogurt, and sour cream
in his diet.
318. Sensory overload is a state in
which sensory stimulation exceeds the
individuals capacity to tolerate or
process it.
319. Symptoms of sensory overload
include a feeling of distress and
hyperarousal with impaired thinking
and concentration.
320. In sensory deprivation, overall
sensory input is decreased.
321. 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.
322. The three stages of general
adaptation syndrome are alarm,
resistance, and exhaustion.
323. A maladaptive response to
stress is drinking alcohol or smoking
excessively.
324. Hyperalertness and the startle
reflex are characteristics of
posttraumatic stress disorder.
325. A treatment for a phobia is
desensitization, a process in which the
patient is slowly exposed to the feared
stimuli.
326. Symptoms of major depressive
disorder include depressed mood,
inability to experience pleasure, sleep
disturbance, appetite changes,
decreased libido, and feelings of
worthlessness.
327. Clinical signs of lithium
toxicity are nausea, vomiting, and
lethargy.
328. Asking too many why
questions yields scant information and
may overwhelm a psychiatric patient
and lead to stress and withdrawal.
329. Remote memory may be
impaired in the late stages of
dementia.
330. According to the DSM-IV,
bipolar II disorder is characterized by
at least one manic episode thats
accompanied by hypomania.
331. The nurse can use silence and
active listening to promote interactions
with a depressed patient.
332. A psychiatric patient with a
substance abuse problem and a major
psychiatric disorder has a dual
diagnosis.
333. When a patient is readmitted
to a mental health unit, the nurse
should assess compliance with
medication orders.
334. Alcohol potentiates the effects
of tricyclic antidepressants.
335. Flight of ideas is movement
from one topic to another without any
discernible connection.
336. Conduct disorder is manifested
by extreme behavior, such as hurting
people and animals.
337. During the tension-building
phase of an abusive relationship, the
abused individual feels helpless.
338. In the emergency treatment of
an alcohol-intoxicated patient,
determining the blood-alcohol level is
paramount in determining the amount
of medication that the patient needs.
339. Side effects of the
antidepressant fluoxetine (Prozac)
include diarrhea, decreased libido,
weight loss, and dry mouth.
340. Before electroconvulsive
therapy, the patient is given the
skeletal muscle relaxant
succinylcholine (Anectine) by I.V.
administration.
341. When a psychotic patient is
admitted to an inpatient facility, the
primary concern is safety, followed by
the establishment of trust.
342. An effective way to decrease
the risk of suicide is to make a suicide
contract with the patient for a
specified period of time.
343. A depressed patient should be
given sufficient portions of his favorite
foods, but shouldnt be overwhelmed
with too much food.
344. The nurse should assess the
depressed patient for suicidal ideation.
345. Delusional thought patterns
commonly occur during the manic
phase of bipolar disorder.
346. Apathy is typically observed in
patients who have schizophrenia.
347. Manipulative behavior is
characteristic of a patient who has
passive aggressive personality
disorder.
348. 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.
349. When a patient who is
receiving an antipsychotic drug
exhibits muscle rigidity and tremors,
the nurse should administer an
antiparkinsonian drug (for example,
Cogentin or Artane) as ordered.
350. A patient who is receiving
lithium (Eskalith) therapy should
report diarrhea, vomiting, drowsiness,
muscular weakness, or lack of
coordination to the physician
immediately.
351. The therapeutic serum level of
lithium (Eskalith) for maintenance is
0.6 to 1.2 mEq/L.
352. Obsessive-compulsive
disorder is an anxiety-related disorder.
353. Al-Anon is a self-help group
for families of alcoholics.
354. Desensitization is a treatment
for phobia, or irrational fear.
355. After electroconvulsive
therapy, the patient is placed in the
lateral position, with the head turned
to one side.
356. A delusion is a fixed false
belief.
357. Giving away personal
possessions is a sign of suicidal
ideation. Other signs include writing a
suicide note or talking about suicide.
358. Agoraphobia is fear of open
spaces.
359. A person who has paranoid
personality disorder projects hostilities
onto others.
360. To assess a patients judgment,
the nurse should ask the patient what
he would do if he found a stamped,
addressed envelope. An appropriate
response is that he would mail the
envelope.
361. After electroconvulsive
therapy, the patient should be
monitored for post-shock amnesia.
362. A mother who continues to
perform cardiopulmonary resuscitation
after a physician pronounces a child
dead is showing denial.
363. Transvestism is a desire to
wear clothes usually worn by members
of the opposite sex.
364. Tardive dyskinesia causes
excessive blinking and unusual
movement of the tongue, and
involuntary sucking and chewing.
365. Trihexyphenidyl (Artane) and
benztropine (Cogentin) are
administered to counteract
extrapyramidal adverse effects.
366. 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.
367. Extrapyramidal symptoms
include parkinsonism, dystonia,
akathisia (ants in the pants), and
tardive dyskinesia.
368. One theory that supports the
use of electroconvulsive therapy
suggests that it resets the brain
circuits to allow normal function.
369. A patient who has obsessive-
compulsive disorder usually
recognizes the senselessness of his
behavior but is powerless to stop it
(ego-dystonia).
370. In helping a patient who has
been abused, physical safety is the
nurses first priority.
371. Pemoline (Cylert) is used to
treat attention deficit hyperactivity
disorder (ADHD).
372. Clozapine (Clozaril) is
contraindicated in pregnant women
and in patients who have severe
granulocytopenia or severe central
nervous system depression.
373. Repression, an unconscious
process, is the inability to recall
painful or unpleasant thoughts or
feelings.
374. Projection is shifting of
unwanted characteristics or
shortcomings to others (scapegoat).
375. Hypnosis is used to treat
psychogenic amnesia.
376. Disulfiram (Antabuse) is
administered orally as an aversion
therapy to treat alcoholism.
377. Ingestion of alcohol by a
patient who is taking disulfiram
(Antabuse) can cause severe reactions,
including nausea and vomiting, and
may endanger the patients life.
378. Improved concentration is a
sign that lithium is taking effect.
379. Behavior modification,
including time-outs, token economy,
or a reward system, is a treatment for
attention deficit hyperactivity disorder.
380. For a patient who has anorexia
nervosa, the nurse should provide
support at mealtime and record the
amount the patient eats.
381. A significant toxic risk
associated with clozapine (Clozaril)
administration is blood dyscrasia.
382. Adverse effects of haloperidol
(Haldol) administration include
drowsiness; insomnia; weakness;
headache; and extrapyramidal
symptoms, such as akathisia, tardive
dyskinesia, and dystonia.
383. Hypervigilance and dj vu are
signs of posttraumatic stress disorder
(PTSD).
384. A child who shows
dissociation has probably been abused.
385. Confabulation is the use of
fantasy to fill in gaps of memory.
Bullets (MCN)
1. 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.
2. 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 infants mouth.
3. Administering high levels of oxygen to a
premature neonate can cause blindness as
a result of retrolental fibroplasia.
4. Amniotomy is artificial rupture of the
amniotic membranes.
5. During pregnancy, weight gain averages
25 to 30 lb (11 to 13.5 kg).
6. Rubella has a teratogenic effect on the
fetus during the first trimester. It produces
abnormalities in up to 40% of cases
without interrupting the pregnancy.
7. Immunity to rubella can be measured by a
hemagglutination inhibition test (rubella
titer). This test identifies exposure to
rubella infection and determines
susceptibility in pregnant women. In a
woman, a titer greater than 1:8 indicates
immunity.
8. When used to describe the degree of fetal
descent during labor, floating means the
presenting part isnt engaged in the pelvic
inlet, but is freely movable (ballotable)
above the pelvic inlet.
9. 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.
10. Fetal station indicates the location of the
presenting part in relation to the ischial
spine. Its described as 1, 2, 3, 4, or
5 to indicate the number of centimeters
above the level of the ischial spine; station
5 is at the pelvic inlet.
11. Fetal station also is described as +1, +2,
+3, +4, or +5 to indicate the number of
centimeters it is below the level of the
ischial spine; station 0 is at the level of the
ischial spine.
12. During the first stage of labor, the side-
lying position usually provides the
greatest degree of comfort, although the
patient may assume any comfortable
position.
13. During delivery, if the umbilical cord
cant be loosened and slipped from around
the neonates neck, it should be clamped
with two clamps and cut between the
clamps.
14. An Apgar score of 7 to 10 indicates no
immediate distress, 4 to 6 indicates
moderate distress, and 0 to 3 indicates
severe distress.
15. To elicit Moros reflex, the nurse holds
the neonate in both hands and suddenly,
but gently, drops the neonates head
backward. 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.
16. 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.
17. Positive signs of pregnancy include
ultrasound evidence, fetal heart tones, and
fetal movement felt by the examiner (not
usually present until 4 months gestation
18. Goodells sign is softening of the cervix.
19. Quickening, a presumptive sign of
pregnancy, occurs between 16 and 19
weeks gestation.
20. Ovulation ceases during pregnancy.
21. Any vaginal bleeding during pregnancy
should be considered a complication until
proven otherwise.
To estimate the date of delivery using
Ngeles rule, the nurse counts backward
3 months from the first day of the last
menstrual period and then adds 7 days to
this date.
22. At 12 weeks gestation, the fundus should
be at the top of the symphysis pubis.
23. Cows milk shouldnt be given to infants
younger than age 1 because it has a low
linoleic acid content and its protein is
difficult for infants to digest.
24. If jaundice is suspected in a neonate, the
nurse should examine the infant under
natural window light. If natural light is
unavailable, the nurse should examine the
infant under a white light.
25. The three phases of a uterine contraction
are increment, acme, and decrement.
26. The intensity of a labor contraction can be
assessed by the indentability of the uterine
wall at the contractions peak. Intensity is
graded as mild (uterine muscle is
somewhat tense), moderate (uterine
muscle is moderately tense), or strong
(uterine muscle is boardlike).
27. Chloasma, the mask of pregnancy, is
pigmentation of a circumscribed area of
skin (usually over the bridge of the nose
and cheeks) that occurs in some pregnant
women.
28. The gynecoid pelvis is most ideal for
delivery. Other types include platypelloid
(flat), anthropoid (apelike), and android
(malelike).
29. Pregnant women should be advised that
there is no safe level of alcohol intake.
30. 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.
31. Vitamin K is administered to neonates to
prevent hemorrhagic disorders because a
neonates intestine cant synthesize
vitamin K.
Before internal fetal monitoring can be
performed, a pregnant patients cervix
must be dilated at least 2 cm, the amniotic
membranes must be ruptured, and the
fetuss presenting part (scalp or buttocks)
must be at station 1 or lower, so that a
small electrode can be attached.
32. Fetal alcohol syndrome presents in the
first 24 hours after birth and produces
lethargy, seizures, poor sucking reflex,
abdominal distention, and respiratory
difficulty.
33. Variability is any change in the fetal heart
rate (FHR) from its normal rate of 120 to
160 beats/minute. Acceleration is
increased FHR; deceleration is decreased
FHR.
34. In a neonate, the symptoms of heroin
withdrawal may begin several hours to 4
days after birth.
35. In a neonate, the symptoms of methadone
withdrawal may begin 7 days to several
weeks after birth.
36. In a neonate, the cardinal signs of narcotic
withdrawal include coarse, flapping
tremors; sleepiness; restlessness;
prolonged, persistent, high-pitched cry;
and irritability.
37. The nurse should count a neonates
respirations for 1 full minute.
38. Chlorpromazine (Thorazine) is used to
treat neonates who are addicted to
narcotics.
39. The nurse should provide a dark, quiet
environment for a neonate who is
experiencing narcotic withdrawal.
40. In a premature neonate, signs of
respiratory distress include nostril flaring,
substernal retractions, and inspiratory
grunting.
41. Respiratory distress syndrome (hyaline
membrane disease) develops in premature
infants because their pulmonary alveoli
lack surfactant.
Whenever an infant is being put down to
sleep, the parent or caregiver should
position the infant on the back.
(Remember back to sleep.)
42. The male sperm contributes an X or a Y
chromosome; the female ovum contributes
an X chromosome.
43. Fertilization produces a total of 46
chromosomes, including an XY
combination (male) or an XX combination
(female).
44. The percentage of water in a neonates
body is about 78% to 80%.
45. 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.
46. Organogenesis occurs during the first
trimester of pregnancy, specifically, days
14 to 56 of gestation.
47. After birth, the neonates umbilical cord is
tied 1 (2.5 cm) from the abdominal wall
with a cotton cord, plastic clamp, or
rubber band.
48. Gravida is the number of pregnancies a
woman has had, regardless of outcome.
49. Para is the number of pregnancies that
reached viability, regardless of whether
the fetus was delivered alive or stillborn.
A fetus is considered viable at 20 weeks
gestation.
An ectopic pregnancy is one that implants
abnormally, outside the uterus.
50. The first stage of labor begins with the
onset of labor and ends with full cervical
dilation at 10 cm.
51. The second stage of labor begins with full
cervical dilation and ends with the
neonates birth.
52. The third stage of labor begins after the
neonates birth and ends with expulsion of
the placenta.
In a full-term neonate, skin creases appear
over two-thirds of the neonates feet.
Preterm neonates have heel creases that
cover less than two-thirds of the feet.
53. The fourth stage of labor (postpartum
stabilization) lasts up to 4 hours after the
placenta is delivered. This time is needed
to stabilize the mothers physical and
emotional state after the stress of
childbirth.
54. At 20 weeks gestation, the fundus is at
the level of the umbilicus.
55. At 36 weeks gestation, the fundus is at
the lower border of the rib cage.
56. A premature neonate is one born before
the end of the 37th week of gestation.
57. Pregnancy-induced hypertension is a
leading cause of maternal death in the
United States.
58. A habitual aborter is a woman who has
had three or more consecutive
spontaneous abortions.
59. Threatened abortion occurs when bleeding
is present without cervical dilation.
60. A complete abortion occurs when all
products of conception are expelled.
61. Hydramnios (polyhydramnios) is
excessive amniotic fluid (more than 2,000
ml in the third trimester).
62. Stress, dehydration, and fatigue may
reduce a breast-feeding mothers milk
supply.
63. During the transition phase of the first
stage of labor, the cervix is dilated 8 to 10
cm and contractions usually occur 2 to 3
minutes apart and last for 60 seconds.
64. A nonstress test is considered nonreactive
(positive) if fewer than two fetal heart rate
accelerations of at least 15 beats/minute
occur in 20 minutes.
65. A nonstress test is considered reactive
(negative) if two or more fetal heart rate
accelerations of 15 beats/minute above
baseline occur in 20 minutes.
66. A nonstress test is usually performed to
assess fetal well-being in a pregnant
patient with a prolonged pregnancy (42
weeks or more), diabetes, a history of poor
pregnancy outcomes, or pregnancy-
induced hypertension.
67. A pregnant woman should drink at least
eight 8-oz glasses (about 2,000 ml) of
water daily.
68. When both breasts are used for breast-
feeding, the infant usually doesnt empty
the second breast. Therefore, the second
breast should be used first at the next
feeding.
69. A low-birth-weight neonate weighs 2,500
g (5 lb 8 oz) or less at birth.
70. A very-low-birth-weight neonate weighs
1,500 g (3 lb 5 oz) or less at birth.
71. 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.
72. 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.
73. Linea nigra, a dark line that extends from
the umbilicus to the mons pubis,
commonly appears during pregnancy and
disappears after pregnancy.
74. Implantation in the uterus occurs 6 to 10
days after ovum fertilization.
75. Placenta previa is abnormally low
implantation of the placenta so that it
encroaches on or covers the cervical os.
76. In complete (total) placenta previa, the
placenta completely covers the cervical
os.
77. In partial (incomplete or marginal)
placenta previa, the placenta covers only a
portion of the cervical os.
78. Abruptio placentae is premature
separation of a normally implanted
placenta. It may be partial or complete,
and usually causes abdominal pain,
vaginal bleeding, and a boardlike
abdomen.
79. Cutis marmorata is mottling or purple
discoloration of the skin. Its a transient
vasomotor response that occurs primarily
in the arms and legs of infants who are
exposed to cold.
80. The classic triad of symptoms of
preeclampsia are hypertension, edema,
and proteinuria. Additional symptoms of
severe preeclampsia include hyperreflexia,
cerebral and vision disturbances, and
epigastric pain.
81. Ortolanis sign (an audible click or
palpable jerk that occurs with thigh
abduction) confirms congenital hip
dislocation in a neonate.
82. The first immunization for a neonate is the
hepatitis B vaccine, which is administered
in the nursery shortly after birth.
83. If a patient misses a menstrual period
while taking an oral contraceptive exactly
as prescribed, she should continue taking
the contraceptive.
84. If a patient misses two consecutive
menstrual periods while taking an oral
contraceptive, she should discontinue the
contraceptive and take a pregnancy test.
85. If a patient who is taking an oral
contraceptive misses a dose, she should
take the pill as soon as she remembers or
take two at the next scheduled interval and
continue with the normal schedule.
86. If a patient who is taking an oral
contraceptive misses two consecutive
doses, she should double the dose for 2
days and then resume her normal
schedule. She also should use an
additional birth control method for 1
week.
87. Eclampsia is the occurrence of seizures
that arent caused by a cerebral disorder in
a patient who has pregnancy-induced
hypertension.
88. In placenta previa, bleeding is painless
and seldom fatal on the first occasion, but
it becomes heavier with each subsequent
episode.
89. Treatment for abruptio placentae is
usually immediate cesarean delivery.
90. Drugs used to treat withdrawal symptoms
in neonates include phenobarbital
(Luminal), camphorated opium tincture
(paregoric), and diazepam (Valium).
91. 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 Moros reflex, and a simian crease on
the hands.
92. The failure rate of a contraceptive is
determined by the experience of 100
women for 1 year. Its expressed as
pregnancies per 100 woman-years.
93. The narrowest diameter of the pelvic inlet
is the anteroposterior (diagonal
conjugate).
94. The chorion is the outermost
extraembryonic membrane that gives rise
to the placenta.
95. The corpus luteum secretes large
quantities of progesterone.
96. From the 8th week of gestation through
delivery, the developing cells are known
as a fetus.
97. In an incomplete abortion, the fetus is
expelled, but parts of the placenta and
membrane remain in the uterus.
98. The circumference of a neonates head is
normally 2 to 3 cm greater than the
circumference of the chest.
99. After administering magnesium sulfate to
a pregnant patient for hypertension or
preterm labor, the nurse should monitor
the respiratory rate and deep tendon
reflexes.
100. During the first hour after birth (the
period of reactivity), the neonate is alert
and awake.
101. When a pregnant patient has
undiagnosed vaginal bleeding, vaginal
examination should be avoided until
ultrasonography rules out placenta previa.
102. After delivery, the first nursing action
is to establish the neonates airway.
103. Nursing interventions for a patient
with placenta previa include positioning
the patient on her left side for maximum
fetal perfusion, monitoring fetal heart
tones, and administering I.V. fluids and
oxygen, as ordered.
104. The specific gravity of a neonates
urine is 1.003 to 1.030. A lower specific
gravity suggests overhydration; a higher
one suggests dehydration.
105. The neonatal period extends from birth
to day 28. Its also called the first 4 weeks
or first month of life.
106. A woman who is breast-feeding
should rub a mild emollient cream or a
few drops of breast milk (or colostrum) on
the nipples after each feeding. She should
let the breasts air-dry to prevent them
from cracking.
107. Breast-feeding mothers should
increase their fluid intake to 2 to 3 qt
(2,500 to 3,000 ml) daily.
108. After feeding an infant with a cleft lip
or palate, the nurse should rinse the
infants mouth with sterile water.
109. The nurse instills erythromycin in a
neonates eyes primarily to prevent
blindness caused by gonorrhea or
chlamydia.
110. Human immunodeficiency virus (HIV)
has been cultured in breast milk and can
be transmitted by an HIV-positive mother
who breast-feeds her infant.
111. A fever in the first 24 hours
postpartum is most likely caused by
dehydration rather than infection.
112. Preterm neonates or neonates who
cant maintain a skin temperature of at
least 97.6 F (36.4 C) should receive care
in an incubator (Isolette) or a radiant
warmer. In a radiant warmer, a heat-
sensitive probe taped to the neonates skin
activates the heater unit automatically to
maintain the desired temperature.
113. During labor, the resting phase
between contractions is at least 30
seconds.
114. Lochia rubra is the vaginal discharge
of almost pure blood that occurs during
the first few days after childbirth.
115. Lochia serosa is the serous vaginal
discharge that occurs 4 to 7 days after
childbirth.
116. Lochia alba is the vaginal discharge of
decreased blood and increased leukocytes
thats the final stage of lochia. It occurs 7
to 10 days after childbirth.
117. Colostrum, the precursor of milk, is
the first secretion from the breasts after
delivery.
118. The length of the uterus increases
from 2 (6.3 cm) before pregnancy to
12 (32 cm) at term.
119. To estimate the true conjugate (the
smallest inlet measurement of the pelvis),
deduct 1.5 cm from the diagonal conjugate
(usually 12 cm). A true conjugate of 10.5
cm enables the fetal head (usually 10 cm)
to pass.
120. The smallest outlet measurement of
the pelvis is the intertuberous diameter,
which is the transverse diameter between
the ischial tuberosities.
121. Electronic fetal monitoring is used to
assess fetal well-being during labor. If
compromised fetal status is suspected,
fetal blood pH may be evaluated by
obtaining a scalp sample.
122. In an emergency delivery, enough
pressure should be applied to the
emerging fetuss head to guide the descent
and prevent a rapid change in pressure
within the molded fetal skull.
123. After delivery, a multiparous woman
is more susceptible to bleeding than a
primiparous woman because her uterine
muscles may be overstretched and may
not contract efficiently.
124. Neonates who are delivered by
cesarean birth have a higher incidence of
respiratory distress syndrome.
125. The nurse should suggest ambulation
to a postpartum patient who has gas pain
and flatulence.
126. Massaging the uterus helps to
stimulate contractions after the placenta is
delivered.
127. When providing phototherapy to a
neonate, the nurse should cover the
neonates eyes and genital area.
128. The narcotic antagonist naloxone
(Narcan) may be given to a neonate to
correct respiratory depression caused by
narcotic administration to the mother
during labor.
129. In a neonate, symptoms of respiratory
distress syndrome include expiratory
grunting or whining, sandpaper breath
sounds, and seesaw retractions.
130. Cerebral palsy presents as
asymmetrical movement, irritability, and
excessive, feeble crying in a long, thin
infant.
131. The nurse should assess a breech-birth
neonate for hydrocephalus, hematomas,
fractures, and other anomalies caused by
birth trauma.
132. When a patient is admitted to the unit
in active labor, the nurses first action is to
listen for fetal heart tones.
133. In a neonate, long, brittle fingernails
are a sign of postmaturity.
134. Desquamation (skin peeling) is
common in postmature neonates.
135. A mother should allow her infant to
breast-feed until the infant is satisfied. The
time may vary from 5 to 20 minutes.
136. Nitrazine paper is used to test the pH
of vaginal discharge to determine the
presence of amniotic fluid.
137. A pregnant patient normally gains 2 to
5 lb (1 to 2.5 kg) during the first trimester
and slightly less than 1 lb (0.5 kg) per
week during the last two trimesters.
138. Neonatal jaundice in the first 24 hours
after birth is known as pathological
jaundice and is a sign of erythroblastosis
fetalis.
139. A classic difference between abruptio
placentae and placenta previa is the degree
of pain. Abruptio placentae causes pain,
whereas placenta previa causes painless
bleeding.
140. Because a major role of the placenta is
to function as a fetal lung, any condition
that interrupts normal blood flow to or
from the placenta increases fetal partial
pressure of arterial carbon dioxide and
decreases fetal pH.
141. Precipitate labor lasts for
approximately 3 hours and ends with
delivery of the neonate.
142. Methylergonovine (Methergine) is an
oxytocic agent used to prevent and treat
postpartum hemorrhage caused by uterine
atony or subinvolution.
143. As emergency treatment for excessive
uterine bleeding, 0.2 mg of
methylergonovine (Methergine) is injected
I.V. over 1 minute while the patients
blood pressure and uterine contractions
are monitored.
144. Braxton Hicks contractions are usually
felt in the abdomen and dont cause
cervical change. True labor contractions
are felt in the front of the abdomen and
back and lead to progressive cervical
dilation and effacement.
145. The average birth weight of neonates
born to mothers who smoke is 6 oz (170
g) less than that of neonates born to
nonsmoking mothers.
146. Culdoscopy is visualization of the
pelvic organs through the posterior
vaginal fornix.
147. The nurse should teach a pregnant
vegetarian to obtain protein from
alternative sources, such as nuts,
soybeans, and legumes.
148. The nurse should instruct a pregnant
patient to take only prescribed prenatal
vitamins because over-the-counter high-
potency vitamins may harm the fetus.
149. High-sodium foods can cause fluid
retention, especially in pregnant patients.
150. A pregnant patient can avoid
constipation and hemorrhoids by adding
fiber to her diet.
151. If a fetus has late decelerations (a sign
of fetal hypoxia), the nurse should instruct
the mother to lie on her left side and then
administer 8 to 10 L of oxygen per minute
by mask or cannula. The nurse should
notify the physician. The side-lying
position removes pressure on the inferior
vena cava.
152. Oxytocin (Pitocin) promotes lactation
and uterine contractions.
153. Lanugo covers the fetuss body until
about 20 weeks gestation. Then it begins
to disappear from the face, trunk, arms,
and legs, in that order.
154. In a neonate, hypoglycemia causes
temperature instability, hypotonia,
jitteriness, and seizures. Premature,
postmature, small-for-gestational-age, and
large-for-gestational-age neonates are
susceptible to this disorder.
155. Neonates typically need to consume
50 to 55 cal per pound of body weight
daily.
156. Because oxytocin (Pitocin) stimulates
powerful uterine contractions during
labor, it must be administered under close
observation to help prevent maternal and
fetal distress.
157. During fetal heart rate monitoring,
variable decelerations indicate
compression or prolapse of the umbilical
cord.
158. Cytomegalovirus is the leading cause
of congenital viral infection.
159. Tocolytic therapy is indicated in
premature labor, but contraindicated in
fetal death, fetal distress, or severe
hemorrhage.
160. Through ultrasonography, the
biophysical profile assesses fetal well-
being by measuring fetal breathing
movements, gross body movements, fetal
tone, reactive fetal heart rate (nonstress
test), and qualitative amniotic fluid
volume.
161. A neonate whose mother has diabetes
should be assessed for hyperinsulinism.
162. In a patient with preeclampsia,
epigastric pain is a late symptom and
requires immediate medical intervention.
163. After a stillbirth, the mother should be
allowed to hold the neonate to help her
come to terms with the death.
164. Molding is the process by which the
fetal head changes shape to facilitate
movement through the birth canal.
165. If a woman receives a spinal block
before delivery, the nurse should monitor
the patients blood pressure closely.
166. If a woman suddenly becomes
hypotensive during labor, the nurse should
increase the infusion rate of I.V. fluids as
prescribed.
167. The best technique for assessing
jaundice in a neonate is to blanch the tip
of the nose or the area just above the
umbilicus.
168. During fetal heart monitoring, early
deceleration is caused by compression of
the head during labor.
169. After the placenta is delivered, the
nurse may add oxytocin (Pitocin) to the
patients I.V. solution, as prescribed, to
promote postpartum involution of the
uterus and stimulate lactation.
170. Pica is a craving to eat nonfood items,
such as dirt, crayons, chalk, glue, starch,
or hair. It may occur during pregnancy
and can endanger the fetus.
171. A pregnant patient should take folic
acid because this nutrient is required for
rapid cell division.
172. A woman who is taking clomiphene
(Clomid) to induce ovulation should be
informed of the possibility of multiple
births with this drug.
173. If needed, cervical suturing is usually
done between 14 and 18 weeks gestation
to reinforce an incompetent cervix and
maintain pregnancy. The suturing is
typically removed by 35 weeks gestation.
During the first trimester, a pregnant
woman should avoid all drugs unless
doing so would adversely affect her
health.
174. Most drugs that a breast-feeding
mother takes appear in breast milk.
175. The Food and Drug Administration
has established the following five
categories of drugs based on their
potential for causing birth defects: A, no
evidence of risk; B, no risk found in
animals, but no studies have been done in
women; C, animal studies have shown an
adverse effect, but the drug may be
beneficial to women despite the potential
risk; D, evidence of risk, but its benefits
may outweigh its risks; and X, fetal
anomalies noted, and the risks clearly
outweigh the potential benefits.
176. A patient with a ruptured ectopic
pregnancy commonly has sharp pain in
the lower abdomen, with spotting and
cramping. She may have abdominal
rigidity; rapid, shallow respirations;
tachycardia; and shock.
177. A patient with a ruptured ectopic
pregnancy commonly has sharp pain in
the lower abdomen, with spotting and
cramping. She may have abdominal
rigidity; rapid, shallow respirations;
tachycardia; and shock.
178. The mechanics of delivery are
engagement, descent and flexion, internal
rotation, extension, external rotation,
restitution, and expulsion.
179. A probable sign of pregnancy,
McDonalds sign is characterized by an
ease in flexing the body of the uterus
against the cervix.
180. Amenorrhea is a probable sign of
pregnancy.
181. A pregnant womans partner should
avoid introducing air into the vagina
during oral sex because of the possibility
of air embolism.
182. The presence of human chorionic
gonadotropin in the blood or urine is a
probable sign of pregnancy.
Radiography isnt usually used in a
pregnant woman because it may harm the
developing fetus. If radiography is
essential, it should be performed only after
36 weeks gestation.
183. A pregnant patient who has had
rupture of the membranes or who is
experiencing vaginal bleeding shouldnt
engage in sexual intercourse.
184. Milia may occur as pinpoint spots over
a neonates nose.
185. 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. Its measured in
seconds.
186. The union of a male and a female
gamete produces a zygote, which divides
into the fertilized ovum.
187. The first menstrual flow is called
menarche and may be anovulatory
(infertile).
188. Spermatozoa (or their fragments)
remain in the vagina for 72 hours after
sexual intercourse.
189. Prolactin stimulates and sustains milk
production.
190. Strabismus is a normal finding in a
neonate.
191. A postpartum patient may resume
sexual intercourse after the perineal or
uterine wounds heal (usually within 4
weeks after delivery).
192. A pregnant staff member shouldnt be
assigned to work with a patient who has
cytomegalovirus infection because the
virus can be transmitted to the fetus.
193. Fetal demise is death of the fetus after
viability.
194. Respiratory distress syndrome
develops in premature neonates because
their alveoli lack surfactant.
195. The most common method of inducing
labor after artificial rupture of the
membranes is oxytocin (Pitocin) infusion.
196. After the amniotic membranes rupture,
the initial nursing action is to assess the
fetal heart rate.
197. The most common reasons for
cesarean birth are malpresentation, fetal
distress, cephalopelvic disproportion,
pregnancy-induced hypertension, previous
cesarean birth, and inadequate progress in
labor.
198. Amniocentesis increases the risk of
spontaneous abortion, trauma to the fetus
or placenta, premature labor, infection,
and Rh sensitization of the fetus.
199. After amniocentesis, abdominal
cramping or spontaneous vaginal bleeding
may indicate complications.
200. To prevent her from developing Rh
antibodies, an Rh-negative primigravida
should receive Rho(D) immune globulin
(RhoGAM) after delivering an Rh-
positive neonate.
201. If a pregnant patients test results are
negative for glucose but positive for
acetone, the nurse should assess the
patients diet for inadequate caloric intake.
202. If a pregnant patients test results are
negative for glucose but positive for
acetone, the nurse should assess the
patients diet for inadequate caloric intake.
203. Rubella infection in a pregnant patient,
especially during the first trimester, can
lead to spontaneous abortion or stillbirth
as well as fetal cardiac and other birth
defects.
204. A pregnant patient should take an iron
supplement to help prevent anemia.
205. Direct antiglobulin (direct Coombs)
test is used to detect maternal antibodies
attached to red blood cells in the neonate.
206. Nausea and vomiting during the first
trimester of pregnancy are caused by
rising levels of the hormone human
chorionic gonadotropin.
207. Before discharging a patient who has
had an abortion, the nurse should instruct
her to report bright red clots, bleeding that
lasts longer than 7 days, or signs of
infection, such as a temperature of greater
than 100 F (37.8 C), foul-smelling
vaginal discharge, severe uterine
cramping, nausea, or vomiting.
208. When informed that a patients
amniotic membrane has broken, the nurse
should check fetal heart tones and then
maternal vital signs.
209. The duration of pregnancy averages
280 days, 40 weeks, 9 calendar months, or
10 lunar months.
210. The initial weight loss for a healthy
neonate is 5% to 10% of birth weight.
211. The normal hemoglobin value in
neonates is 17 to 20 g/dl.
212. Crowning is the appearance of the
fetuss head when its largest diameter is
encircled by the vulvovaginal ring.
213. 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.
214. In a pregnant patient, preeclampsia
may progress to eclampsia, which is
characterized by seizures and may lead to
coma.
215. The Apgar score is used to assess the
neonates vital functions. Its obtained at 1
minute and 5 minutes after delivery. The
score is based on respiratory effort, heart
rate, muscle tone, reflex irritability, and
color.
216. Because of the anti-insulin effects of
placental hormones, insulin requirements
increase during the third trimester.
217. Gestational age can be estimated by
ultrasound measurement of maternal
abdominal circumference, fetal femur
length, and fetal head size. These
measurements are most accurate between
12 and 18 weeks gestation.
218. Skeletal system abnormalities and
ventricular septal defects are the most
common disorders of infants who are born
to diabetic women. The incidence of
congenital malformation is three times
higher in these infants than in those born
to nondiabetic women.
219. Skeletal system abnormalities and
ventricular septal defects are the most
common disorders of infants who are born
to diabetic women. The incidence of
congenital malformation is three times
higher in these infants than in those born
to nondiabetic women.
220. The patient with preeclampsia usually
has puffiness around the eyes or edema in
the hands (for example, I cant put my
wedding ring on.).
221. Kegel exercises require contraction
and relaxation of the perineal muscles.
These exercises help strengthen pelvic
muscles and improve urine control in
postpartum patients.
222. Symptoms of postpartum depression
range from mild postpartum blues to
intense, suicidal, depressive psychosis.
223. The preterm neonate may require
gavage feedings because of a weak
sucking reflex, uncoordinated sucking, or
respiratory distress.
224. Acrocyanosis (blueness and coolness
of the arms and legs) is normal in
neonates because of their immature
peripheral circulatory system.
225. To prevent ophthalmia neonatorum (a
severe eye infection caused by maternal
gonorrhea), the nurse may administer one
of three drugs, as prescribed, in the
neonates eyes: tetracycline, silver nitrate,
or erythromycin.
Neonatal testing for phenylketonuria is
mandatory in most states.
226. The nurse should place the neonate in
a 30-degree Trendelenburg position to
facilitate mucus drainage.
227. The nurse may suction the neonates
nose and mouth as needed with a bulb
syringe or suction trap.
228. 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.
229. The umbilical cord normally has two
arteries and one vein.
230. When providing care, the nurse should
expose only one part of an infants body at
a time.
231. Lightening is settling of the fetal head
into the brim of the pelvis.
232. If the neonate is stable, the mother
should be allowed to breast-feed within
the neonates first hour of life.
233. The nurse should check the neonates
temperature every 1 to 2 hours until its
maintained within normal limits.
At birth, a neonate normally weighs 5 to 9
lb (2 to 4 kg), measures 18 to 22 (45.5
to 56 cm) in length, has a head
circumference of 13 to 14 (34 to 35.5
cm), and has a chest circumference thats
1 (2.5 cm) less than the head
circumference.
234. In the neonate, temperature normally
ranges from 98 to 99 F (36.7 to 37.2
C), apical pulse rate averages 120 to 160
beats/minute, and respirations are 40 to 60
breaths/minute.
235. The diamond-shaped anterior fontanel
usually closes between ages 12 and 18
months. The triangular posterior fontanel
usually closes by age 2 months.
236. In the neonate, a straight spine is
normal. A tuft of hair over the spine is an
abnormal finding.
237. Prostaglandin gel may be applied to
the vagina or cervix to ripen an
unfavorable cervix before labor induction
with oxytocin (Pitocin).
238. Supernumerary nipples are
occasionally seen on neonates. They
usually appear along a line that runs from
each axilla, through the normal nipple
area, and to the groin.
239. Meconium is a material that collects in
the fetuss intestines and forms the
neonates first feces, which are black and
tarry.
240. The presence of meconium in the
amniotic fluid during labor indicates
possible fetal distress and the need to
evaluate the neonate for meconium
aspiration.
241. To assess a neonates rooting reflex,
the nurse touches a finger to the cheek or
the corner of the mouth. Normally, the
neonate turns his head toward the
stimulus, opens his mouth, and searches
for the stimulus.
242. Harlequin sign is present when a
neonate who is lying on his side appears
red on the dependent side and pale on the
upper side.
243. Mongolian spots can range from
brown to blue. Their color depends on
how close melanocytes are to the surface
of the skin. They most commonly appear
as patches across the sacrum, buttocks,
and legs.
244. Mongolian spots are common in non-
white infants and usually disappear by age
2 to 3 years.
245. Vernix caseosa is a cheeselike
substance that covers and protects the
fetuss skin in utero. It may be rubbed into
the neonates skin or washed away in one
or two baths.
246. Caput succedaneum is edema that
develops in and under the fetal scalp
during labor and delivery. It resolves
spontaneously and presents no danger to
the neonate. The edema doesnt cross the
suture line.
247. Nevus flammeus, or port-wine stain, is
a diffuse pink to dark bluish red lesion on
a neonates face or neck.
248. The Guthrie test (a screening test for
phenylketonuria) is most reliable if its
done between the second and sixth days
after birth and is performed after the
neonate has ingested protein.
249. To assess coordination of sucking and
swallowing, the nurse should observe the
neonates first breast-feeding or sterile
water bottle-feeding.
250. To establish a milk supply pattern, the
mother should breast-feed her infant at
least every 4 hours. During the first
month, she should breast-feed 8 to 12
times daily (demand feeding).
251. To avoid contact with blood and other
body fluids, the nurse should wear gloves
when handling the neonate until after the
first bath is given.
252. If a breast-fed infant is content, has
good skin turgor, an adequate number of
wet diapers, and normal weight gain, the
mothers milk supply is assumed to be
adequate.
253. In the supine position, a pregnant
patients enlarged uterus impairs venous
return from the lower half of the body to
the heart, resulting in supine hypotensive
syndrome, or inferior vena cava
syndrome.
254. Tocolytic agents used to treat preterm
labor include terbutaline (Brethine),
ritodrine (Yutopar), and magnesium
sulfate.
255. A pregnant woman who has
hyperemesis gravidarum may require
hospitalization to treat dehydration and
starvation.
256. Diaphragmatic hernia is one of the
most urgent neonatal surgical
emergencies. By compressing and
displacing the lungs and heart, this
disorder can cause respiratory distress
shortly after birth.
257. Common complications of early
pregnancy (up to 20 weeks gestation)
include fetal loss and serious threats to
maternal health.
258. Fetal embodiment is a maternal
developmental task that occurs in the
second trimester. During this stage, the
mother may complain that she never gets
to sleep because the fetus always gives her
a thump when she tries.
259. Visualization in pregnancy is a process
in which the mother imagines what the
child shes carrying is like and becomes
acquainted with it.
260. Hemodilution of pregnancy is the
increase in blood volume that occurs
during pregnancy. 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.
261. Mean arterial pressure of greater than
100 mm Hg after 20 weeks of pregnancy
is considered hypertension.
262. The treatment for supine hypotension
syndrome (a condition that sometimes
occurs in pregnancy) is to have the patient
lie on her left side.
263. 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).
264. Hyperpigmentation of the pregnant
patients face, formerly called chloasma
and now referred to as melasma, fades
after delivery.
265. 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.
266. Progesterone maintains the integrity of
the pregnancy by inhibiting uterine
motility.
267. Ladins sign, an early indication of
pregnancy, causes softening of a spot on
the anterior portion of the uterus, just
above the uterocervical juncture.
268. During pregnancy, the abdominal line
from the symphysis pubis to the umbilicus
changes from linea alba to linea nigra.
269. In neonates, cold stress affects the
circulatory, regulatory, and respiratory
systems.
270. 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).
271. Parity doesnt refer to the number of
infants delivered, only the number of
deliveries.
272. Women who are carrying more than
one fetus should be encouraged to gain 35
to 45 lb (15.5 to 20.5 kg) during
pregnancy.
273. The recommended amount of iron
supplement for the pregnant patient is 30
to 60 mg daily.
274. Drinking six alcoholic beverages a day
or a single episode of binge drinking in
the first trimester can cause fetal alcohol
syndrome.
Chorionic villus sampling is performed at
8 to 12 weeks of pregnancy for early
identification of genetic defects.
275. In percutaneous umbilical blood
sampling, a blood sample is obtained from
the umbilical cord to detect anemia,
genetic defects, and blood incompatibility
as well as to assess the need for blood
transfusions.
276. The period between contractions is
referred to as the interval, or resting phase.
During this phase, the uterus and placenta
fill with blood and allow for the exchange
of oxygen, carbon dioxide, and nutrients.
277. In a patient who has hypertonic
contractions, the uterus doesnt have an
opportunity to relax and there is no
interval between contractions. As a result,
the fetus may experience hypoxia or rapid
delivery may occur.
278. Two qualities of the myometrium are
elasticity, which allows it to stretch yet
maintain its tone, and contractility, which
allows it to shorten and lengthen in a
synchronized pattern.
279. During crowning, the presenting part
of the fetus remains visible during the
interval between contractions.
280. Uterine atony is failure of the uterus to
remain firmly contracted.
281. The major cause of uterine atony is a
full bladder.
282. If the mother wishes to breast-feed, the
neonate should be nursed as soon as
possible after delivery.
283. A smacking sound, milk dripping from
the side of the mouth, and sucking noises
all indicate improper placement of the
infants mouth over the nipple.
284. Before feeding is initiated, an infant
should be burped to expel air from the
stomach.
285. Most authorities strongly encourage
the continuation of breast-feeding on both
the affected and the unaffected breast of
patients with mastitis.
286. Neonates are nearsighted and focus on
items that are held 10 to 12 (25 to 30.5
cm) away.
287. In a neonate, low-set ears are
associated with chromosomal
abnormalities such as Down syndrome.
288. Meconium is usually passed in the
first 24 hours; however, passage may take
up to 72 hours.
289. Boys who are born with hypospadias
shouldnt be circumcised at birth because
the foreskin may be needed for
constructive surgery.
290. In the neonate, the normal blood
glucose level is 45 to 90 mg/dl.
291. Hepatitis B vaccine is usually given
within 48 hours of birth.
292. Hepatitis B immune globulin is
usually given within 12 hours of birth.
293. HELLP (hemolysis, elevated liver
enzymes, and low platelets) syndrome is
an unusual variation of pregnancy-induced
hypertension.
294. Maternal serum alpha-fetoprotein is
detectable at 7 weeks of gestation and
peaks in the third trimester. High levels
detected between the 16th and 18th weeks
are associated with neural tube defects.
Low levels are associated with Down
syndrome.
295. An arrest of descent occurs when the
fetus doesnt descend through the pelvic
cavity during labor. Its commonly
associated with cephalopelvic
disproportion, and cesarean delivery may
be required.
296. A late sign of preeclampsia is
epigastric pain as a result of severe liver
edema.
297. In the patient with preeclampsia, blood
pressure returns to normal during the
puerperal period.
298. To obtain an estriol level, urine is
collected for 24 hours.
299. An estriol level is used to assess fetal
well-being and maternal renal functioning
as well as to monitor a pregnancy thats
complicated by diabetes.
300. A pregnant patient with vaginal
bleeding shouldnt have a pelvic
examination.
301. In the early stages of pregnancy, the
finding of glucose in the urine may be
related to the increased shunting of
glucose to the developing placenta,
without a corresponding increase in the
reabsorption capability of the kidneys.
302. A patient who has premature rupture
of the membranes is at significant risk for
infection if labor doesnt begin within 24
hours.
303. Infants of diabetic mothers are
susceptible to macrosomia as a result of
increased insulin production in the fetus.
304. To prevent heat loss in the neonate,
the nurse should bathe one part of his
body at a time and keep the rest of the
body covered.
305. A patient who has a cesarean delivery
is at greater risk for infection than the
patient who gives birth vaginally.
306. The occurrence of thrush in the
neonate is probably caused by contact
with the organism during delivery through
the birth canal.
307. The nurse should keep the sac of
meningomyelocele moist with normal
saline solution.
308. If fundal height is at least 2 cm less
than expected, the cause may be growth
retardation, missed abortion, transverse
lie, or false pregnancy.
309. Fundal height that exceeds
expectations by more than 2 cm may be
caused by multiple gestation,
polyhydramnios, uterine myomata, or a
large baby.
310. A major developmental task for a
woman during the first trimester of
pregnancy is accepting the pregnancy.
311. Unlike formula, breast milk offers the
benefit of maternal antibodies.
312. Spontaneous rupture of the
membranes increases the risk of a
prolapsed umbilical cord.
313. A clinical manifestation of a prolapsed
umbilical cord is variable decelerations.
314. During labor, to relieve supine
hypotension manifested by nausea and
vomiting and paleness, turn the patient on
her left side.
315. If the ovum is fertilized by a
spermatozoon carrying a Y chromosome,
a male zygote is formed.
316. Implantation occurs when the cellular
walls of the blastocyte implants itself in
the endometrium, usually 7 to 9 days after
fertilization.
317. Implantation occurs when the cellular
walls of the blastocyte implants itself in
the endometrium, usually 7 to 9 days after
fertilization.
318. Heart development in the embryo
begins at 2 to 4 weeks and is complete by
the end of the embryonic stage.
319. Methergine stimulates uterine
contractions.
320. The administration of folic acid during
the early stages of gestation may prevent
neural tube defects.
321. With advanced maternal age, a
common genetic problem is Down
syndrome.
322. With early maternal age,
cephalopelvic disproportion commonly
occurs.
323. In the early postpartum period, the
fundus should be midline at the umbilicus.
324. A rubella vaccine shouldnt be given
to a pregnant woman. The vaccine can be
administered after delivery, but the patient
should be instructed to avoid becoming
pregnant for 3 months.
325. A 16-year-old girl who is pregnant is
at risk for having a low-birth-weight
neonate.
326. The mothers Rh factor should be
determined before an amniocentesis is
performed.
327. Maternal hypotension is a
complication of spinal block.
328. After delivery, if the fundus is boggy
and deviated to the right side, the patient
should empty her bladder.
329. Before providing a specimen for a
sperm count, the patient should avoid
ejaculation for 48 to 72 hours.
330. The hormone human chorionic
gonadotropin is a marker for pregnancy.
331. Painless vaginal bleeding during the
last trimester of pregnancy may indicate
placenta previa.
332. During the transition phase of labor,
the woman usually is irritable and restless.
333. 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.
334. To avoid puncturing the placenta, a
vaginal examination shouldnt be
performed on a pregnant patient who is
bleeding.
335. A patient who has postpartum
hemorrhage caused by uterine atony
should be given oxytocin as prescribed.
336. Laceration of the vagina, cervix, or
perineum produces bright red bleeding
that often comes in spurts. The bleeding is
continuous, even when the fundus is firm.
337. Hot compresses can help to relieve
breast tenderness after breast-feeding.
338. The fundus of a postpartum patient is
massaged to stimulate contraction of the
uterus and prevent hemorrhage.
339. A mother who has a positive human
immunodeficiency virus test result
shouldnt breast-feed her infant.
340. Dinoprostone (Cervidil) is used to
ripen the cervix.
341. Breast-feeding of a premature neonate
born at 32 weeks gestation can be
accomplished if the mother expresses milk
and feeds the neonate by gavage.
342. If a pregnant patients rubella titer is
less than 1:8, she should be immunized
after delivery.
343. The administration of oxytocin
(Pitocin) is stopped if the contractions are
90 seconds or longer.
344. For an extramural delivery (one that
takes place outside of a normal delivery
center), the priorities for care of the
neonate include maintaining a patent
airway, supporting efforts to breathe,
monitoring vital signs, and maintaining
adequate body temperature.
345. Subinvolution may occur if the
bladder is distended after delivery.
346. The nurse must place identification
bands on both the mother and the neonate
before they leave the delivery room.
347. Erythromycin is given at birth to
prevent ophthalmia neonatorum.
348. Pelvic-tilt exercises can help to
prevent or relieve backache during
pregnancy.
349. Before performing a Leopold
maneuver, the nurse should ask the patient
to empty her bladder.
350. According to the Unang Yakap
program (Essential Newborn Care), the
cord should not be clamped until
pulsations have stopped (thats about 1-3
minutes).
Bullets (PEDIATRIC)
1. A child with HIV-positive blood should
receive inactivated poliovirus vaccine
(IPV) rather than oral poliovirus vaccine
(OPV) immunization.
2. To achieve postural drainage in an infant,
place a pillow on the nurses lap and lay
the infant across it.
3. A child with cystic fibrosis should eat
more calories, protein, vitamins, and
minerals than a child without the disease.
4. Infants subsisting on cows milk only
dont receive a sufficient amount of iron
(ferrous sulfate), which will eventually
result in iron deficiency anemia.
5. A child with an undiagnosed infection
should be placed in isolation.
6. An infant usually triples his birth weight
by the end of his first year.
7. Clinical signs of a dehydrated infant
include lethargy, irritability, dry skin
decreased tearing, decreased urinary
output, and increased pulse.
8. Appropriate care of a child with
meningitis includes frequent assessment
of neurologic signs (such as decreasing
levels of consciousness, difficulty to
arouse) and measuring the circumference
of the head because subdural effusions
and obstructive hydrocephalus can
develop.
9. Expected clinical findings in a newborn
with cerebral palsy include reflexive
hypertonicity and criss-crossing or
scissoring leg movements.
10. Papules, vesicles, and crust are all present
at the same time in the early phase of
chickenpox.
11. Topical corticosteroids shouldnt be used
on chickenpox lesions.
12. A serving size of a food is usually 1
tablespoon for each year of age.
13. The characteristic of fifth disease
(erythema infectiosum) is erythema on the
face, primarily the cheeks, giving a
slapped face appearance.
14. Adolescents may brave pain, especially in
front of peers. Therefore, offer analgesics
if pain is suspected or administer the
medication if the client asks for it.
15. Signs that a child with cystic fibrosis is
responding to pancreatic enzymes are the
absence of steatorrhea, improved appetite,
and absence of abdominal pain.
16. Roseola appears as discrete rose-pink
macules that first appear on the trunk and
that fade when pressure is applied.
17. A ninety degree-ninety degree traction is
used for fracture of a childs femur or
tibia.
18. One sign of developmental dysplasia is
limping during ambulation.
19. Circumcision wouldnt be performed on a
male child with hypospadias because the
foreskin may be needed during surgical
reconstruction.
20. Neonatal abstinence syndrome is
manifested in central nervous system
hyperirritability (for example, hyperactive
Moro reflex) and gastrointestinal
symptoms (watery stools).
21. Classic signs of shaken baby syndrome
are seizures, slow apical pulse difficulty
breathing, and retinal hemorrhage.
22. An infant born to an HIV-positive mother
will usually receive AZT (zidovudine) for
the first 6 weeks of life.
23. Infants born to an HIV-positive mother
should receive all immunizations of
schedule.
24. Blood pressure in the arms and legs is
essentially the same in infants.
25. When bottle-feeding a newborn with a
cleft palate, hold the infants head in an
upright position.
26. Because of circulating maternal antibodies
that will decrease the immune response,
the measles, mumps, and rubella (MMR)
vaccine shouldnt be given until the infant
has reached 1 year of age.
27. 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.
28. A newborn typically wets 6 to 10 diapers
per day.
29. Although microwaving food and fluids
isnt recommend for infants, its
commonplace in the United States.
Therefore the family should be toughs to
test the temperature of the food or fluid
against their own skin before allowing it
to be consumed by the infant.
30. The most adequate diet for an infant in the
first 6 months of life is breast milk.
31. An infant can usually chew food by 7
months, hold spoon by 9 month, and drink
fluid from a cup by 1 year of age.
32. Choking from mechanical obstruction is
the leading cause of death (by suffocation)
for infants younger than 1 year of age.
33. Failure to thrive is a term used to describe
an infant who falls below the fifth
percentile for weight and height on a
standard measurement chart.
34. Developmental theories include
Havighursts age periods and
developmental tasks; Freuds five stages
of development;
35. Kohlbergs stages of moral development;
Eriksons eight stages of development;
and Piagets phases of cognitive
development.
36. The primary concern with infusing large
volumes of fluid is circulatory overload.
This is especially true in children and
infants, and in clients with renal disease.
37. Certain hazards present increased risk of
harm to children and occur more often at
different ages. 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.
38. A child in Bryants traction whos
younger than age 3 or weighs less than 30
lb (13.6 kg) should have the buttocks
slightly elevated and clear or the bed. The
knees should be slightly flexed, and the
legs should be extended at a right angle to
the body.
39. The body provides the traction
mechanism.
40. In an infant, a bulging fontanel is the most
significant sign of increasing intracranial
pressure.