Semester 4 Unit 1 lecture exam

(Nclex) When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?

a.) BP 88/56 mm Hg

b.) Apical pulse 110 beats/min

c.) Urine output 15 ml for 2 hours

d.) Arterial oxygen saturation 90%

c.) Urine output 15 ml for 2 hours

Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

(med surg) Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety?

a. Set hot water temperature at 140° F.

b. Use only hardwired smoke detectors.

c. Encourage regular home fire exit drills.

d. Never permit older adults to cook unattended

c. Encourage regular home fire exit drills.

(med surg) The injury that is least likely to result in a full-thickness burn is

a. sunburn.

b. scald injury.

c. chemical burn.

d. electrical injury.

a. sunburn.

(med surg) A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next?

a. Encourage the patient to cough and auscultate the lungs again.

b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.

c. Document the findings and continue to monitor the patient's breathing.

d. Anticipate the need for endotracheal intubation and notify the physician.

d. Anticipate the need for endotracheal intubation and notify the physician.

(med surg) Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include

a. adherence of albumin to vascular walls.

b. movement of potassium into the vascular space.

c. sequestering of sodium and water in interstitial fluid.

d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c. sequestering of sodium and water in interstitial fluid.

(med surg) To maintain a positive nitrogen balance in a major burn, the patient must

a. eat a high-protein, high-carbohydrate diet.

b. increase normal caloric intake by about three times.

c. eat at least 1500 calories/day in small, frequent meals.

d. eat a gluten-free diet for the chemical effect on nitrogen balance.

a. eat a high-protein, high-carbohydrate diet.

(med surg) Pain management for the burn patient is most effective when (select all that apply)

a. a pain rating tool is used to monitor the patient's level of pain.

b. painful dressing changes are delayed until the patient's pain is completely relieved.

c. the patient is informed about and has some control over the management of the pain.

d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics).

e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a. a pain rating tool is used to monitor the patient's level of pain.

c. the patient is informed about and has some control over the management of the pain.

d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics).

(med surg) A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is

a. applying pressure garments.

b. repositioning the patient every 2 hours.

c. performing active ROM at least every 4 hours.

d. massaging the new tissue with water-based moisturizers.

a. applying pressure garments. Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

(Powerpoints question)

Why does major hypotension occur in septic shock

A. Decreased CO

B. Increased SVR

C. Decreased SVR

D. Increased preload

C. Decreased SVR

due to vasodilation

(Nurse Sarah) A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock.

A. obstructive; hypovolemic and anaphylactic

B. distributive; anaphylactic and neurogenic

C. obstructive; cardiogenic and neurogenic

D. distributive; anaphylactic and cardiogenic

The answer is B. Septic shock is a form of distributive shock. This means there is an issue with the distribution of blood flow in the small blood vessels of the body. This results in a diminished supply of blood to the body's tissues and organs. Anaphylactic and neurogenic shock are also a type of distributive form of shock. Septic shock isn't occurring due to an issue with cardiac output, which occurs in hypovolemic and cardiogenic shock.

(Nurse Sarah) Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply:

A. Blood pressure of 70/34 after the fluid bolus

B. Serum lactate less than 2 mmol/L

C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement

D. Central venous pressure (CVP) of 18

The answers are A and C. To know if the patient is progressing to septic shock, you need to think about the hallmark findings associated with this condition. Septic shock is characterized by major persistent hypotension (<90 SBP) that doesn't respond to IV fluids (refractory hypotension), and the patient needs vasopressors (ex: Norepinephrine) to maintain a mean arterial pressure greater than 65 and their serum lactate is greater than 2 mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs are not functioning properly due to low oxygen; hence tissue perfusion is poor due to the low blood pressure and mean arterial pressure.

(Nurse Sarah) You're providing care to four patients. Select all the patients who are at risk for developing sepsis:

A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place.

B. A 55-year-old male who is a recent kidney transplant recipient.

C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery.

D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

All the answers are correct. All the patients have risk factors for developing sepsis. Remember the mnemonic: Septic.....Suppressed immune system (AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy, malnutrition)....Extreme age (infants and elderly)...Post-op (surgical/invasive procedures)....Transplant recipients.....Indwelling devices (Foley catheter, central lines, trachs).....Chronic diseases (diabetes, hepatitis, alcoholism, renal insufficiency)

(Nurse Sarah) A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply:

A. Absolute hypovolemia

B. Vasodilation

C. Increased capillary permeability

D. Increased systemic vascular resistance

E. Clot formation in microcirculation

F. A significantly decreased cardiac output

The answers are B, C, and E. Septic shock occurs due to sepsis. Sepsis is the body's reaction to an infection and will lead to septic shock if this reaction is not treated. This reaction is the activation of the body's inflammatory system, but it's MAJORLY amplified and system wide. Cardiac output is not the problem in septic shock as with other types of shocks like hypovolemic or cardiogenic. CO is actually high or normal during the early stages of septic shock. It only decreases to the end of septic shock when heart function fails. The issue is with what is going on beyond the heart in the vessels. Substances are released by the microorganism that has invaded the body. This causes the immune system to release substances that will cause system wide vasodilation of the vessels (this will cause a DECREASE in systemic vascular resistance, blood to pool, and this decreases blood flow to the organs/tissues) along with an increase in capillary permeability (this causes fluid to leave the intravascular system and depletes the circulatory system of fluid and further decreases blood flow to the organs/fluids...this is RELATIVE (not absolute) hypovolemia). Furthermore, clots will form in the microcirculation due to plasma activating factor being released. This will cause platelets to aggregate and block blood flow even more to the organs/tissues. All of this will lead to decreased tissue perfusion and deprive cells of oxygen.

(Nurse Sarah) Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply:

A. MAP (mean arterial pressure) 40 mmHg

B. Urinary output of 10 mL over 2 hours

C. Serum Lactate 15 mmol/L

D. Blood glucose 120 mg/dL

E. CVP (central venous pressure) less than 2 mmHg

The answers are A, B, C, and E. When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.

(Nurse Sarah) A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT?

A. IV corticosteroids

B. Colloids

C. Dobutamine

D. Norepinephrine

The answer is D. Fluids are ordered FIRST in septic shock. If this is unsuccessful, then vasopressors are ordered NEXT. Norepinephrine is used as a first-line agent. Dobutamine may sometimes be used but for its inotropic effects on the heart.

(Nurse Sarah) Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST?

A. Low-dose corticosteroids

B. Crystalloids IV fluid bolus

C. Norepinephrine

D. 2 units of Packed Red Blood Cells

The answer is B. The first treatment in regards to helping maintain tissue perfusion is fluid replacement with either crystalloid or colloid solutions. THEN vasopressors like Norepinephrine are ordered if the fluids don't help.

A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply:

A. Urinary output of 60 mL over 4 hours

B. Warm and flushed skin

C. Tachycardia

D. Bradypnea

The answers are B and C. In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.

(powerpoint)

Three leading cause of obstructive shock are (select all that apply)

A. PE

B. spinal cord injuries above T5

C. Cardiac tamponade

D. Tension pneumothorax

A. PE

C. Cardiac tamponade

D. Tension pneumothorax

Which type of shock would you worry the most about in a patient with a tension pneumothorax

A. Distributive

B. Obstructive

C. Cardiogenic

D. Septic

B. Obstructive

Tension causes pressure/obstruction on the venous system

(med surg) A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing

a. a relative hypervolemia.

b. an absolute hypovolemia.

c. neurogenic shock from low blood flow.

d. neurogenic shock from massive vasodilation.

d. neurogenic shock from massive vasodilation.

(anaphylactic, neurogenic, and septic shock are all considered distributive shock and are caused by vasodilation)

(med surg) A 78-yr-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of

a. sepsis.

b. septic shock.

c. multiple organ dysfunction syndrome.

d. systemic inflammatory response syndrome.

b. septic shock.

(med surg) Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply)

a. dobutamine to increase myocardial contractility.

b. vasopressors to increase systemic vascular resistance

c. circulatory assist devices such as an intraaortic balloon pump.

d. corticosteroids to stabilize the cell wall in the infarcted myocardium.

e. Trendelenburg positioning to facilitate venous return and increase preload.

a. dobutamine to increase myocardial contractility.

c. circulatory assist devices such as an intraaortic balloon pump.

(med surg) The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are

a. blood pressure, pulse, and respirations.

b. breath sounds, blood pressure, and body temperature.

c. pulse pressure, level of consciousness, and pupillary response.

d. level of consciousness, urine output, and skin color and temperature.

d. level of consciousness, urine output, and skin color and temperature.

ARDS occurs during the ______________ stage of shock while MODS occurs during the _________ stage of shock

Progressive stage--> ARDS

Refractory --> MODS

(nurse sarah) A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that apply:

A. "The patient will experience an increase in cardiac output due to an increase in preload and afterload."

B. "A patient with this condition will experience decreased cardiac output and decreased tissue perfusion."

C. "This condition occurs because the heart has an inadequate blood volume to pump."

D. "Cardiogenic shock leads to pulmonary edema."

The answers are: B and D. Cardiogenic shock occurs when the heart can NOT pump enough blood to meet the perfusion needs of the body. The cardiac output will be DECREASED, which will DECREASE tissue perfusion and cause cell injury to organs/tissues. In this condition, the heart is WEAK and can't pump blood out of the heart. This can be due to either a systolic (contraction) or diastolic (filling) issue along with a structural or dysrhythmia issue. In cardiogenic shock, there is NOT an issue with blood volume, but there is a problem with the heart itself.

(nurse sarah) Cardiac output is very important for determining if a patient is in cardiogenic shock. What is a normal cardiac output in an adult?

A. 2-5 liters/minute

B. 1-3 liters/minute

C. 4-8 liters/minute

D. 8-10 liters/minute

The answer is C. Cardiac output is the amount of blood the heart pumps per minute. The heart's cardiac output should be anywhere from 4-8 liters of blood per minute.

(nurse sarah) ________________ is the amount the ventricle stretches at the end of diastole.

A. Preload

B. Afterload

C. Stroke Volume

D. Contractility

The answer is A. Preload is the amount the ventricle stretches at the end of diastole (hence it's the amount the ventricles stretches once it's filled with blood and right before the contraction of the ventricle ....so it's the end-diastolic volume).

(nurse sarah) Cardiac output is equal to the heart rate multiplied by the stroke volume. Treatment for cardiogenic shock includes medications that increase cardiac output. One of the factors that help determine cardiac output is stroke volume. Select all the factors that determine stroke volume?

A. Cardiac Index

B. Preload

C. Pulmonary capillary wedge pressure

D. Afterload

E. Heart rate

F. Contractility

The answers are B, D, and F. Cardiac output is determined by the person's heart rate times the stroke volume. Stroke volume is the amount of blood pumped from the left ventricle with each BEAT (50-100 ml). It's determined by the preload, afterload, and contractility of the heart. These factors in a patient with cardiogenic shock can be manipulated with medications to increase the cardiac output.

(nurse sarah) _____________ is the force the heart has to pump against to get blood out of the ventricle.

A. Cardiac output

B. Cardiac index

C. Preload

D. Afterload

The answer is D. Afterload is the pressure the ventricle must pump against to squeeze blood out. In other words, it's the force the heart has to pump against to get blood out of the ventricle.

(nurse sarah) A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification?

A. Dopamine IV stat

B. Normal saline IV bolus stat

C. Furosemide IV stat

D. Place patient on CPAP (continuous positive airway pressure)

The answer is B. This patient with cardiogenic shock is experiencing a decrease in cardiac output (hence the blood pressure), so an order for Dopamine can help provide a positive inotropic effect (increase the contractility of the heart which will increase stroke volume and cardiac output). The patient is also experiencing pulmonary congestion due to the cardiogenic shock. The heart is failing to pump blood forward, so it is backing up in the lungs. This is leading to an increased respiratory rate, dyspnea, and low oxygen saturation. The order for Furosemide (which is a diuretic) will help remove the extra fluid volume from the lungs and the CPAP (continuous positive airway pressure) will help with oxygenation. The nurse would question the order for a normal saline IV bolus. This bolus would add more fluid to the lungs and further congest the fluids.

(nurse sarah) You're assessing your patient with cardiogenic shock, what signs and symptoms do you expect to find in this condition? Select all that apply:

A. Warm, flushed skin

B. Prolonged capillary refill

C. Urinary output >30 mL/hr

D. Systolic blood pressure <90 mmHg

E. Crackles in lung fields

F. Dyspnea

D. Decreased BUN and creatinine

G. Strong peripheral pulses

H. Chest pain

The answers are B, D, E, F, and H. Signs and symptoms of cardiogenic shock will be related to LOW cardiac output and decreased perfusion to organs/tissues. Capillary refill will be prolonged >2 seconds, urinary output will be <30 mL/hr, systolic blood pressure will be <90 mmHg, pulmonary edema will present with fluid in the lungs (hence crackles in the lungs), dyspnea, and chest pain (due to decreased blood flow to the heart muscle).

(nurse sarah) A patient with cardiogenic shock has an intra-aortic balloon pump. As the nurse you know that during ________ the balloon deflates and during _____ the balloon inflates in a section of the aorta.

A. systole, diastole

B. diastole, systole

C. inspiration, expiration

D. expiration, inspiration

The answer is A. An intra-aortic balloon pump is a balloon attached to the catheter inside a section of the aorta. It will inflate and deflate during systole (contraction) and diastole (relaxation). When the balloon deflates during systole it creates a suction-like pressure that will draw blood out of the weak heart and into the coronary arteries and systemic circulation (hence increasing cardiac output and blood supply to the heart muscle). When the balloon inflates during diastole it will create pressure that will push blood into the coronary arteries (hence further increasing blood supply to the heart muscle).

(nurse sarah) You're precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an intra-aortic balloon pump? Select all that apply:

A. "This device increases the cardiac afterload, which will increase cardiac output."

B. "This device will help increase blood flow to the coronary arteries."

C. "The balloon pump will help remove extra fluid from the heart and lungs."

D. "The balloon pump will help increase cardiac output."

The answers are B and D. An intra-aortic balloon pump increases coronary artery blood flow and cardiac output.

( med surg) To establish hemodynamic monitoring for a patient, the nurse zeros the

a. cardiac output monitoring system to the level of the left ventricle.

b. pressure monitoring system to the level of the catheter tip located in the patient.

c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis.

d. pressure monitoring system to the level of the atrium, identified as the midclavicular line.

c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis.

(med surg)

The hemodynamic changes the nurse expects to find after successful initiation of intraaortic balloon pump therapy in a patient with cardiogenic shock include (select all that apply)

a. decreased SV.

b. decreased SVR.

c. decreased PAWP.

d. increased diastolic BP.

e. decreased myocardial O2 consumption.

b. decreased SVR.

c. decreased PAWP.

d. increased diastolic BP.

e. decreased myocardial O2 consumption.

If the burn is large (greater than 10% TBSA) or an electrical or inhalation burn is suspected and the patient is unresponsive, first focus your attention on

A. Airway: Check for patency, soot around nares and on the tongue, singed nasal hair, darkened oral or nasal membranes.

B. Breathing: Check for adequacy of ventilation.

C. Circulation: Check for presence of pulses and elevate the burned limb(s) above the heart to decrease pain and swelling.

C. Circulation: Check for presence of pulses and elevate the burned limb(s) above the heart to decrease pain and swelling.

If the burn is large (greater than 10% TBSA) or an electrical or inhalation burn is suspected and the patient is unresponsive, first focus your attention on CAB

(if responsive follow ABC’s)

On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse’s immediate therapeutic response be?

A. Ignoring the client at this time

B. Stating that this behavior is unacceptable

C. Moving him to his room for a short time-out

D. Telling the client to come to the office later to discuss the behavior

B. Stating that this behavior is unacceptable

(med surg)

A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to

a. arrange a return-to-clinic appointment and prescription for pain medications

b. teach the patient and the caregiver proper wound care to be performed at home

c. review the patient's current health care status and readiness for discharge to home

d. give the patient written information and websites for information for burn survivors

c. review the patient's current health care status and readiness for discharge to home

Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The burn care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to

a. reapply a new dressing without disturbing the wound bed

b. observe the wound for signs of infection during dressing changes

c. apply cool compresses for pain relief in between dressing changes

d. wash the wound aggressively with soap and water three times a day

b. observe the wound for signs of infection during dressing changesRationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply)

a. blisters

b. exposed fascia

c. exposed muscles

d. intact nerve endingse. red, shiny, wet appearance

a. blisters

d. intact nerve endingse. red, shiny, wet appearanceRationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

Neurogenic shock is characterized by (select all that apply)

A. Elevated temperature

B. Hypotension

C. Tachycardia

D. Bradycardia

B. Hypotension

D. Bradycardia

You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply:

A. A 36-year-old with a spinal cord injury at L4.

B. A 42-year-old who has spinal anesthesia.

C. A 25-year-old with a spinal cord injury above T6.

D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

The answers are B and C. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

Answer: FALSE....the statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock?

A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension.

B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring.

C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension.

D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

The answer is B. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply:

A. Blood pressure 69/38

B. Heart rate 170 bpm

C. Blood pressure 250/120

D. Heart rate 29

E. Warm and dry extremities

F. Cool and clammy extremities

G. Temperature 104.9 'F

H. Temperature 95 'F

The answers are A, D, E, and H. Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities).

In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring:

A. Loss of vasomotor tone

B. Increase systemic vascular resistance

C. Decrease in cardiac preload

D. Increase in cardiac afterload

E. Decrease in venous blood return to the heart

F. Venous blood pooling in the extremities

The answers are A, C, E, and F. Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.

You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?

A. Keeping the head of the bed greater than 45 degrees at all times.

B. Repositioning the patient every thirty minutes.

C. Keeping the patient's spine immobilized.

D. Avoiding log-rolling the patient during transport.

The answer is C. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.

A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report?

A. Increase in blood pressure

B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP)

C. Urinary output of 300 mL in the past 5 hours

D. Mean arterial pressure (MAP) 85 mmHg

The answer is B. Option B would indicate the patient is in fluid volume overload. Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase the blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT?

A. Adenosine

B. Warfarin

C. Atropine

D. Norepinephrine

The answer is C. Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working?

A. Decreased CVP (central venous pressure)

B. Mean arterial pressure (MAP) 90 mmHg

C. Serum lactate 6 mmol/L

D. Blood pH 7.20

The answer is B. A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal:

A. Perform range of motion exercises daily.

B. Place a pillow underneath the patient knees as needed

.

C. Administer anticoagulants as scheduled per physician's order.

D. Apply compression stockings daily.

The answers are A, C, and D. Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.

Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply:

A. MAP (mean arterial pressure) 40 mmHg

B. Urinary output of 10 mL over 2 hours

C. Serum Lactate 15 mmol/L

D. Blood glucose 120 mg/dL

E. CVP (central venous pressure) less than 2 mmHg

The answers are A, B, C, and E. When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient?

A. The patient's blood pressure changes from 75/48 to 110/82.

B. Patient's CVP 2 mmHg

C. Patient's skin is warm and flushed.

D. Patient's urinary output is 20 mL/hr.

The answer is A. In septic shock, the first treatment is to try to maintain tissue perfusion with fluids. If that doesn't work to increase the blood pressure and maintain perfusion, vasopressors will be used next. In septic shock, the intravascular space will be depleted of fluid due to an increase in capillary permeability. This will lead to hypovolemia, which will decrease blood pressure and lead to a decrease in blood flow to organs/tissue. If the blood pressure increases to a normal state, that tells us the fluids are working.

Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient?

A. Administer Norepinephrine before attempting a fluid resuscitation.

B. Collect cultures and then administer IV antibiotics.

C. Check blood glucose levels before starting any other treatments.

D. Administer Drotrecogin Alpha within 48-72 hours.

The answer is B. This is the only correct option. Option A is wrong because fluids are administered first, and if they don't work vasopressors (Norepinephrine) is administered. Option C is wrong because although blood glucose levels should be measured, it does not take precedence over other treatments. Option D is wrong because Drotrecogin alpha should be given within 24-48 hours of septic shock to be the most effective.

A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be:

A. <110 mg/dL

B. <80 mg/dL

C. >200 mg/dL

D. <180 mg/dL

The answer is D. If a patient is experiencing hyperglycemia an insulin drip may be ordered to control glucose levels. Hyperglycemia affects the immune system and healing. A blood glucose goal in this patient is <180 mg/dL.

A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication?

A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater."

B. "This medication causes vasodilation and decreases systemic vascular resistance."

C. "It is used when fluid replacement is not unsuccessful."

D. "It is considered a vasopressor."

The answer is B. This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.

What will the nurse identify as symptoms of hypovolemic shock in a patient?(select all that apply)

1. Temperature of 97.6°F (36.4°C)

2. Restlessness

3. Decrease in blood pressure of 20 mm Hg when the patient sits up

4. Capillary refill time greater than 3 seconds

5. Sinus bradycardia of 55 beats per minute

Correct Answer: 2,3,4

Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate.

Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status.Rationale

3: Orthostatic hypotension is a manifestation of hypovolemic shock.

Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.

Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.

The nurse differentiates the types of treatment that are appropriate for each type of shock. Match the type of shock with the type of treatment associated with it.

1.Cardiogenic shock

2.Hypovolemic shock

3.Anaphylactic shock

4.Neurogenic shock

A. Administration of epinephrine

B. Administration of vasoconstrictors

C. Administration of fluids

D. Administration of vasodilators

1.Cardiogenic shock-->D. Administration of vasodilators

2.Hypovolemic shock--> C. Administration of fluids

3.Anaphylactic shock--> A. Administration of epinephrine

4.Neurogenic shock--> B. Administration of vasoconstrictors

A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?

A. An increase in cardiac preload

B. An increase in stroke volume

C. A decrease in cardiac preload

D. A decrease in cardiac contractility

The answer is C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won't be stretching too much because there isn't enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.

Select all the conditions below that increases a patient's risk for absolute hypovolemic shock:

A. Burns

B. Vomiting

C. Long bone fracture

D. Surgery

E. Diarrhea

F. Sepsis

The answers are: B, D, and E. Vomiting, diarrhea, and surgery can all increase the loss of fluid volume outside the body, which are absolute hypovolemic shock types. Burns, long bone fracture, and sepsis can lead to an inside fluid shift of fluid from the intravascular system and are relative hypovolemic shock types.

One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:

A. Temperature 104.8 'F

B. Heart rate 40 bpm

C. Heart rate 140 bpm

D. Anxiety, restlessness

E. Urinary output 15 mL/hr

F. Blood pressure 70/56

G. Pale, cool skin

H. Weak peripheral pulses

I. Blood pressure 220/106

The answers are: C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses

A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?

A. Collect a urine sample

B. Obtain an EKG

C. Establish 2 large-bore IV access sites

D. Place a warming blanket on the patient

The answer is C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock...where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula....18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.

A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?

A. Patient heart rate is 115 bpm

B. Patient experiences dyspnea and crackles in lung fields

C. Patient is anxious

D. Patient's urinary output is 35 mL/hr

The answer is B. When crystalloid fluids are given there is a risk for fluid volume overload even though the patient is hypovolemic, especially with rapid infusions. Therefore, the nurse should monitor the patient for this. If a patient develops difficulty breathing (dyspnea) and has crackles in the lung fields (this represents edema in the lungs), fluid is backing up in the lungs. This requires immediate nursing action. Option A and C are expected finding in hypovolemic shock, and option D is a normal finding...urinary output should be >30 mL/hr.

A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?

A. Rapidly infuse the fluids

B. Warm the fluids

C. Change tubing in between bags

D. Keep the patient supine

B. Warm the fluids

The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.

The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient?

A. Platelets

B. Albumin

C. Fresh Frozen Plasma

D. Packed Red Blood Cells

The answer is C. A patient who needs clotting factors would benefit from fresh frozen plasma (FFP).

One of the most frequent causes of hypovolemic shock in children is:

a.Myocardial infarction.

c.Anaphylaxis.

b.Blood loss.

d.Congenital heart disease.

ANS: B

Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to contribute to hypervolemia, not hypovolemia

(powerpoints)

Most common delusions involve: (select all that apply:)

A. erotomanic

B. persecutory

C. grandiose

D. Religious ideal

B. persecutory

C. grandiose

D. Religious ideal

The client newly diagnosed with paranoid schizophrenia tells the nurse "those weird people in the corner are laughing at me, and calling me names." Which response by the nurse is most appropriate? Which response from the nurse is most appropriate ?

A. Since I can't see anything there, you have nothing to be afraid of

B. Tell me more about the voices are telling you

C. I don't hear any voice, but this sounds like a frightening experience for you

D. Sometimes when you are upset you imagine things and your mind plays tricks on you, especially when you have schizophrenia

Answer: C

This statement the nurse is helping the patient separate altered perceptions from reality, the nurse is protecting the client's ego by not arguing, humiliating, or attempting to talk to the client out their hallucination, the nurse is also acknowledging the patients feelings

(powerpoints) What is the goal in the acute phase of schizophrenia ?

A. Patient safety and stabilization

B. Relapse prevention are made

C. Patient understand illness and treatment plan

D. Patient is able to live independently

A. Patient safety and stabilization

Effective long term care of patients with schizophrenia relies (select all that apply):

A. Medication

B. Patient achievement of accepted cognitive and social skills

C. Treatment adherence

D. Relationships with trusted care providers and support people

E. Community-based therapeutic services

A. Medication

C. Treatment adherence

D. Relationships with trusted care providers and support people

E. Community-based therapeutic services

A patient has had schizophrenia for the past 15 years and is treated with first-generation antipsychotics and bromocriptine (Parlodel). The nurse suspects that the patient is not following the schedule for taking bromocriptine (Parlodel) regularly. What complications does the nurse evaluate in the patient during assessment? Select all that apply.

A. Muscular rigidity

B. Neutropenia

C. Hyperpyrexia

D. Deep vein thrombosis

E. Sexual dysfunction

A. Muscular rigidity

C.Hyperpyrexia

D. Deep vein thrombosis

Neuroleptic malignant syndrome is caused by excessive reduction in dopamine functions due to receptor blockage. Schizophrenic patients who take first- and second-generation antipsychotic drugs for 15 to 20 years may develop neuroleptic malignant syndrome. Patients are prescribed bromocriptine (Parlodel) to treat neuroleptic malignant syndrome. The nurse should evaluate muscular rigidity in patients as neuroleptic malignant syndrome is characterized by muscular rigidity, hyperpyrexia, and deep vein thrombosis. Neutropenia is caused by agranulocytosis and is seen in patients who are treated with clozapine (Clozaril), a second-generation antipsychotic drug. Sexual dysfunction is not a characteristic of neuroleptic malignant syndrome. It is a common side effect of antipsychotic drugs.

Which diagnostic finding associated with structural brain anomalies has been observed in patients diagnosed with schizophrenia? Select all that apply.

A. Enlargement of the lateral cerebral ventricles

B. Increased size of the sulci (fissures) on the brain's surface

C. Increased cortical thickness

D. Increased frontal lobe volume

E. Reduced connectivity in various brain regions

A. Enlargement of the lateral cerebral ventricles

B. Increased size of the sulci (fissures) on the brain's surface

E. Reduced connectivity in various brain regions

Brain imaging techniques provide substantial evidence that some people with schizophrenia have structural brain abnormalities that include the following: enlargement of the lateral cerebral ventricles, reduced frontal lobe volume, increased size of the sulci (fissures) on the surface of the brain, reduced cortical thickness, and reduced connectivity in various brain regions.

What statement is true regarding schizophrenia? Select all that apply.

A. The disorder disturbs a person's ability to determine what is or is not real.

B. This disorder moderately impacts the individual's quality of life.

C. Schizophrenia is a potentially devastating brain disorder.

D. The disorder often affects an individual's language and thinking skills.

E. Social behavior and emotions are affected by schizophrenia.

A. The disorder disturbs a person's ability to determine what is or is not real.

C. Schizophrenia is a potentially devastating brain disorder.

D. The disorder often affects an individual's language and thinking skills.

E. Social behavior and emotions are affected by schizophrenia.

Schizophrenia spectrum and other psychotic disorders disturb the fundamental inability to determine what is or is not real. Schizophrenia is a potentially devastating brain disorder that affects a person's thinking, language, emotions, social behavior, and ability to perceive reality accurately. It affects over 3.5 million people in the United States and is among the most disruptive and disabling of mental disorders.Varcolis p. 201

A community mental health nurse cares for a patient diagnosed with schizophrenia who takes olanzapine (Zyprexa). In addition to monitoring the patient's mental status, the nurse regularly should assess what of the patient? Select all that apply.

A. Peripheral pulses

B. Blood pressure

C. Blood glucose

D. Weight

E. Height

A. Peripheral pulses

B. Blood pressure

C. Blood glucose

Olanzapine is a second-generation antipsychotic medication. These medications have a high risk of causing metabolic syndrome. It is important to monitor blood glucose, weight, and serum lipids, as well as indicators of diabetes, atherosclerotic heart disease, and hypertension. Height is not relevant

A patient with schizophrenia says, "I could hear the dog barking. It is trying to bite me." The nurse has taught hallucination-coping techniques to the patient's family to facilitate the patient's rehabilitation at home. What would be the most appropriate action by the patient's family in this case? Select all that apply.

A. The family members should ask the patient to cover his or her ears.

B. The family members should ask the patient to read loudly

C. The family members should ask the patient not to go anywhere.

D. The family members should ask the patient to close his or her eyes.

E. The family members would ask the patient to clean the house

B. The family members should ask the patient to read loudly

E. The family members would ask the patient to clean the house

It is helpful if family members are included in the treatment of a patient with schizophrenia. They form a support group for the patient and thus are taught different coping techniques for hallucinations and delusions. It is useful to use other auditory stimuli to overcome auditory hallucination in patients with schizophrenia. The patient should be asked to read loudly or listen to music in such cases. The patient may also be engaged in an activity like cleaning the house. Asking the patient to cover the ears will not help the patient to overcome auditory hallucinations. The patient should be taken to a favorite place so he or she can relax. Asking the patient to close his or her eyes will not help the patient to overcome hallucinations.

The achievement of long-term treatment goals for a patient diagnosed with schizophrenia is reliant upon which factor? ( select all that apply)

a. A trusting nurse-patient relationship

b. Patient adherence to treatment plan

c. Patient achievement of accepted cognitive and social skills

d. Medication therapy that is reviewed regularly for effectivenesse.

E. Patient interaction with community-based therapeutic services

a. A trusting nurse-patient relationship

b. Patient adherence to treatment plan

d. Medication therapy that is reviewed regularly for effectivenesse.

E. Patient interaction with community-based therapeutic services

Effective long-term care of persons with schizophrenia relies on a three-pronged approach: medication administration/adherence, relationships with trusted care providers, and community-based therapeutic services. Cognitive and social skills are not relevant.

A schizophrenic patient was prescribed perphenazine (Trilafon). During the follow-up visit after 12 weeks on the medication, the nurse suggests that the patient go on bed rest and follow a diet rich in proteins and carbohydrates. Which is the most appropriate reason for the nurse to give this suggestion?

A. The patient has the symptoms of postural hypotension.

B. The patient has the symptoms of agranulocytosis.

C. The patient has the symptoms of cholestatic jaundice.

D. The patient has the symptoms of autonomic dysfunction

C. The patient has the symptoms of cholestatic jaundice.

Schizophrenic patients taking perphenazine (Trilafon), a first-generation antipsychotic drug, may have toxic effects due to long-term therapy. The nurse should identify the signs and symptoms of the toxic effects, like cholestatic jaundice, which is due to collection of bile juice in the gallbladder. The patient should be instructed to go on bed rest and consume a diet rich in proteins and carbohydrates. Postural hypotension is characterized by a drop in blood pressure with a change in position. It cannot be managed by a protein-rich diet. Agranulocytosis is characterized by dangerously low levels of white blood cells; this condition is not related to bed rest and diet changes. Autonomic nervous system controls involuntary actions of the body. An autonomic dysfunction is not treated by bed rest and diet changes.

The nurse demonstrates an understanding of the most common comorbid condition observed in a schizophrenic individual when asking:

A. "Have you ever been diagnosed with an eating disorder?"

B. "How often do you drink enough alcohol to get drunk?"

C. "How old were you when you became sexually active?"

D. "Would you describe yourself as being depressed?"

B. "How often do you drink enough alcohol to get drunk?"

About 50% of patients with schizophrenia have a co-occurring substance abuse disorder, most frequently alcohol or cannabis. Assessing alcohol consumption patterns will help identify this comorbid condition. Eating disorders generally are not observed in the schizophrenic individual. Sexual habits are not generally viewed as being abnormal in the schizophrenic individual. Although depression may occur, it is not a primary comorbid condition

Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia?

a. Always afraid another student will steal her belongings.

b. An unusual interest in numbers and specific topics.

c. Demonstrates no interest in athletics or organized sports.

d. Appears more comfortable among males.

a. Always afraid another student will steal her belongings.

Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia?

a. Screening a group of males between the ages of 15 and 25 for early symptoms.

b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use issues.

c. Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective.

d. Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention.

a. Screening a group of males between the ages of 15 and 25 for early symptoms.

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should:

a.sit close to the patient.

b.place an arm protectively around the patient's shoulders.

c.place a hand on the patient's arm and exert light pressure.

d.maintain a normal social interaction distance from the patient.

d.maintain a normal social interaction distance from the patient.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

a.Avoid the use of anticoagulant medications.

b.Measure the patient's urinary output every hour.

c.Provide passive range of motion for all extremities.

d.Position the patient supine with head flat at all times.

ANS:B

Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the ba

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.

a."How long has the voice been directing your behavior?"

b."Does what the voice tell you to do frighten you?"

c."Do you recognize the voice speaking to you?'

d."What is the voice telling you to do?"

ANS:D

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?

a.Heart rate is slow at 58 beats/min.

b.Mean arterial pressure (MAP) is 56 mm Hg.

c.Systemic vascular resistance (SVR) is elevated.

d.Pulmonary artery wedge pressure (PAWP) is low.

ANS:C

Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.

Which drug must be administered along with chlorpromazine (Thorazine) in schizophrenic patients to reduce extrapyramidal side effects?

1) Trihexiphenidyl (Artane)

2) Montelukast (Singulair)

3) Lamivudine (Epivir)

4) Valacyclovir (Valtrex)

1) Trihexiphenidyl (Artane)

The type of altered perception most commonly experienced by patients with schizophrenia is

a. Delusions

b. Illusions

c. Tactile hallucinations

d. Auditory hallucinations

d. Auditory hallucinations

When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that:

a. Medications provided are ineffective.

b. Nurses are trying to control their minds.

c. The medications will make them sick.

d. They are not actually ill.

d. They are not actually ill.

Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

a. "I know you say you hear voices, but I cannot hear them."

b. "Stop listening to the voices, they are NOT real."

c. "You say you hear voices, what are they telling you?"

d. "Please tell the voices to leave you alone for now."

c. "You say you hear voices, what are they telling you?"

To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.

a. Alcohol use disorder

b. Major depressive disorder

c. stomach cancer

d. Polydipsia

e. Metabolic syndrome

a. Alcohol use disorder

b. Major depressive disorder

d. Polydipsia

e. Metabolic syndrome

The nurse cares for a client who has schizophrenia and is taking chlorpromazine. The nurse instructs the family members to inform the nurse if any adverse effects develop. Which side effects are considered late extrapyramidal side effects?

A. Tremors

B. Restless movements

C. Muscle spasms of neck

D. Worm-like tongue movements

D. Worm-like tongue movements

Chlorpromazine is a first-generation antipsychotic drug that may cause extrapyramidal side effects. Late extrapyramidal side effects include fine, worm-like tongue movements. Tremors, restless movements, and muscle spasms of the neck, back, tongue, or face are early extrapyramidal side effects.

antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to achieve what purpose?

A. Keep the client quiet and relaxed.

B. Control the client's behavior and reduce stress.

C. Reduce the client's need for physical restraints.

D. Make the client more receptive to psychotherapy.

Antipsychotic/neuroleptic medications help control anxiety, improve cognition, and decrease acting-out behavior, rendering the client better able to participate in therapy. Although the medication may keep the client quiet and relaxed, control the client's behavior and reduce stress, or prevent the need for restraints, none of these is the primary purpose of administration.

To provide effective care for the pt diagnosed with schizophrenia the nurse should frequently asses for which associated conditions? Select all that apply

A. Alcohol use disorder

B. Major depressive disorder

C. Stomach cancer

D. Polydipsia

E. Metabolic syndrome

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, I dont like taking pills. Which treatment strategy should the nurse discuss with the health care provider?

a. Use of a long-acting antipsychotic injections

b. Addition of a benzodiazepine, such as lorazepam (Ativan)

c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil)

d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

ANS: A

Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patients dislike of taking pills