ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 8 Questions
Question 1 of 5
A young adult arrives in the emergency department (ED) with multiple abrasions after a motor vehicle accident and has an initial blood pressure (BP) of 180/98. Which of the following interventions should the nurse implement?
Correct Answer: C
Rationale: Because hypertension is expected when a patient has experienced an acute stressor, the nurse should plan to check the BP in a timely manner, which will provide a more accurate idea of the patient's usual blood pressure. Hypertension that occurs in response to acute stress does not increase risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.
Question 2 of 5
A hospitalized patient whose wife describes him as usually well organized and calm is receiving diabetic teaching after being newly diagnosed with diabetes. He states, 'I'm feeling distracted because I'm just getting used to my new diagnosis'. Which action should the nurse take?
Correct Answer: D
Rationale: Since behavioural responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.
Question 3 of 5
The nurse is caring for a patient who has been hospitalized following a heart attack and tells the nurse, 'I didn't sleep last night because I worried about missing work and losing my insurance coverage.' Which nursing diagnosis is appropriate to include in the plan of care?
Correct Answer: A
Rationale: The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk-prone health behaviour as problems for this patient.
Question 4 of 5
The nurse is assisting with a breast biopsy for an alert patient who has a lump in the right breast. Which relaxation technique will be best to use at this time?
Correct Answer: D
Rationale: Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practise and learn.
Question 5 of 5
The nurse is preparing a health-promotion session on meditation for older persons at a community centre. Which of the following points should the nurse include in the session?
Correct Answer: C
Rationale: Guidelines for basic mediation include continuing it for 10-20 minutes, although even 5 minutes can be helpful. Patients won't bring earphones as the guideline is to find a quiet place with no distractions. The breathing pattern is to breathe slowly and consistently, relaxation breathing, not to speed up the rate. Meditation guidelines suggest that this be done once or twice a day.