1, A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client’s fundus is firm, located 2 fingerbreadths above the umbilicus. And deviated to the left. Which of the following actions should the nurse take first?

A, Notify the provider.
B, Administer a prescribed analgesic.
C, Monitor perineal pads for clots.
D, Assist the client to empty her bladder.
2, A nurse is reinforcing teaching about an amniocentesis with a client who is at 34 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

A, “You should report uterine contractions following the procedure to your provider.”
B, “You should take milk of magnesia the night prior to the procedure.”
C, “You will have blood work drawn before the procedure.”
D, “You should anticipate a small amount of leakage of fluid following the procedure.”

3.A nurse on a postpartum unit is caring for a client who delivered vaginally 24hr ago. Which of the following should the nurse expect to find when collecting data?

A, Frequent urges to urinate
B, Moderate lochia serosa on perineal pads
C, Colostrum expressed from the breast
D, Uterine fundus 2 finger widths above the umbilicus

4. A nurse is assisting in the care of a client who is experiencing an unruptured ectopic pregnancy that is at 8 weeks of gestation. Which of the following medications should the nurse expect the provider to prescribe?

A, Methotrexate
B, Calcium gluconate
C, Terbutaline
D, Magnesium sulfate

5. A Nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

A, “I may have developed discoloration on my cheeks from hormonal changes.”
B, “I should expect my fingers and face to be swollen.”
C, “I may have an infection if I develop a dark line in the middle of my abdomen.”
D ” I should expect to have burning when I urinate during the third trimester.”

7. A nurse is collecting data from a newborn who was born 2 hr ago. Which of the following findings should the nurse report to the provider?

A, Blood glucose level 40 mg/dl
B, Hypotonia
C, Overlapping suture lines
D, Acrocyanosis

8.A nurse in a clinic is discussing contraceptive methods with a client. Which of the following methods should the nurse recommend as having the lowest failure rate?

A, Intrauterine device
B, Diaphragm
C, Contraceptive sponge
D, Oral contraceptives

9. A nurse is reinforcing teaching about car seat safety with a new parent. Which of the following statements should the nurse include in the teaching?

A, “You should place the shoulder harness at the level of your baby’s shoulders.”
B, “You should keep the car seat rear facing unit when your baby is 6 months old .”
C, “You should position your baby in the car seat at a 30- degree angle.”
“D, You should place the retainer clip at the level of your baby’s abdomen.”

10.A nurse working on a postpartum unit is collecting data from four clients.Which of the following findings should the nurse report to the provider?

A, A client who reports their perineal pad every2 hr?
B, Aclient who reports painful uterine contractions during breastfeeding
C, A client who has a reddened area on their right calf
D, A client who has a urinary output of 125 mL in 4 hr

11. A Nurse in an antepartum clinic is reinforcing teaching with a client who is pregnant and has a new prescription for oral ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?
A, “I will take this medication with a glass of orange juice.”
B, “I will take this medication with breakfast.”
C, “I will take this medication with a glass of milk.”
D, “I will take this medication with my middy meal.”

12 A nurse is collecting data from a newborn who is 1 hr old and was born at 43 weeks of gestation. Which of the following findings should the nurse expect?

A, Long hard nails
B, Excessive lanugo
C, Absent vernix
D, Dry,cracked skin
E, Hypotonia

14. A nurse is planning care for a newborn who is large for gestational age.Which of the following actions should the nurse include in the plan of care?

A, Check the newborn’s blood glucose level.
B, Obtain a stool sample of meconium.
C, Check the newborn’s skin for ecchymosis.
D, Assist with administering a blood transfusion to the newborn.

15. A nurse is preparing to administer metronidazole 2 g po. The amount available is 500mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number.Use a leading zero if it applies. Do not use a trailing zero.)
————-tablets.

17. A nurse is reinforcing teaching about home safety precautions with the guardian of a newborn. Which of the following instructions should the nurse include?

A, Wash the newborn’s face with a warm, soapy washcloth.
B, Ensure the crib has soft bumper pads on the inside.
C, Place a small pillow under the newborn’s head during naps.
D, Set the temperature on the water heater to 48.8dgree C (120 degree.F).

18.A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is reviving morphine for pain. Which of the following findings is the nurse’s priority?

A, Urinary retention
B, BP 105/62 mm Hg
C, Respiratory rate 11/min
D, Blurred vision

19. A nurse is collecting data from a term newborn who is 12hr old. Which of the following findings should the nurse report to the provider?
A, Abdominal breathing
B, Irregular respirations
C, Respiratory rate 55/min
D, Grunting

20.A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected Breast.Which of the following instructions should the nurse include?

A, Tell the client to apply hydrocortisone ointment to the affected area of the breast.
B, Encourage the client to limit oral fluid intake to decrease milk production.
C, Suggest the client apply warm compresses to the affected breast .
D, Recommend the client avoid wearing a nursing bra until symptoms resolve.

21. A nurse is preparing to collect a specimen for the newborn screaming. Which of the following actions should the nurse take?

A, Warm the newborn’s heel for 5to 10 min before the puncture.
B, Apply an antiseptic to the newborn’s heel after collecting the specimen.
C, Use a lancet to puncture the inner aspect of the newborn’s heel.
D, Leave the newborn’s heel open to the air after the puncture.

22. A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
A, “I will need an amniocentesis within 1 month.”
B, “I will need home panative services after I am discharged from the hospital.”
C, “I will need to start chemotherapy immediately.”
D, “I will need to attend a support group when I get home .”
23. A nurse is contributing to the plan of care for a newborn who required phototherapy for hyperbilirubinemia.Which of the following interventions should the nurse recommend including in the plan?

A, Imposition the newborn every2 to 3 hr.
B, Monitor the newborn’s blood glucose level every 2 hr .
C, Apply a water- based ointment to the newborn’s skin every 4 to 6hr.
D, Gave the newborn 30 mL of distilled water after each feeding.

24. A Nurse is collecting data from a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse report to the provider?

A, Dizziness
B, Nausea
C, Termos
D, Crackies

26.A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago. Which of the following manifestations is a possible indication of postpartum hemorrhage?
A, Apical pulse 66 min
B, Blood pressure 156/80 mm Hg
C, Respiratory rate 32/min
D, Temperature 38.3dgree C(101 degreeF)

27. A nurse is collecting data from a client at a 6-week postpartum checkup. The client tells the nurse.”I am breastfeeding and would like to use a birth control pill.” Which of the following statements should the nurse make?

A, ” Birth control pills are contraindicated for breastfeeding clients.”
B, “Progestin-only birth control pills are preferred for contraception during lactation.”
C, “You do not need a birth control pill as long as you are lactating.”
D, “Taking birth control pills while breastfeeding can increase your risk for breast cancer.”

29. A nurse is reinforcing teaching about safety measures for preventing newborn abduction with a client who is postpartum. Which of the following statements should the nurse make?

A, “Carry your baby in your arms when you go for a walk in the hallway.”
B, ” If your baby’s identification band slips off. Place it in the drawer of the bassinet.”
C, “Make sure anyone caring for or transporting your baby is wearing an identification badge.”
D, “Place your baby in the bassinet in your room by the bed when you use the bathroom.”
32. A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation . Where should the nurse expect to auscultate the fetal heart tones?

A, Umbilical area
B, Below the liver border on the right abdomen
C, Above the left iliac crest
D, Suprapublic area

33. A nurse is reinforcing teaching about laboratory testing with a client who is at 6 weeks of gestation. Which of the statements should the nurse include?

A, “You will have a group B strep culture at 36 weeks of gestation.”
B “You will have Maternal serum alpha-fetoprotein screening at 6 weeks of gestation.”
C, “You will have a screening for gestational diabetes at 12 weeks of gestation.”
D, “You will have to produce a clean catch urine specimen every 2 months.”

35. A nurse is caring for a client who is 34 weeks of gestation and is preparing to undergo a nonstress test.
A, Instruct the client that oxytocin is administered during the procedure.
B, Ensure the client has been NPO for 6hr prior to the procedure.
C, Assist the client to a lateral tilt position prior to the procedure.
D, Inform the client that this procedure assists in indicting Down syndrome .

36. A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

A, Tachycardia
B ,Tachypnea
C, Fever
D, Hypertension
37. A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

A, Check the mother’s Rh factor prior to administration.
B, Administer the medication 12 hr after birth.
C, Administer the medication with a 25-gauge needle.
D, Administer the medication into the deltoid muscle.

38. A nurse is caring for a client who is in the early stages of labor and requests non pharmacological interventions for pain. Which of the following actions should the nurse take?

A, Assist the client in remaining awake between contractions.
B, Encourage the client to vold often.
C, Minimize the clients position changes .
D, Limit the amount of the time the support person remains in the room.

40. A nurse is assisting a provider with a pelvic examination of a client during her first prenatal visit. Which of the following actions should the nurse take?

A, Assist the client into a Sim’s position prior to the procedure.
B, Instruct the client to tighten her pelvic muscles during the procedure.
C, Ask the client to empty her bladder prior to the procedure.
D, Encourage the client to take rapid,shallow breaths during the procedure.

41. A nurse is preparing to collect a blood specimen from a newborn via a heel stick.Identify the sequence of steps the nurse should follow. (Move the steps into the box on the
right . Placing them in the order of performance . Use all the steps.)

Conform the newborn’s identity.
Apply gentle pressure to the site with dry gauze.
Cleanse the site with an antiseptic.
Warm the newborn’s heel.
Pierce the newborn’s heel.

42. Anurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client’s blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take

A, Administer methylergonovine IM.
B, Place the client in a knee-chest position.
C, Give a bolus of lactated Ringer’s.
D, Assist the clients to empty her bladder.

43. A nurse is caring for a client who reports discomfort due to afterpains following breastfeeding. Which of the following actions should the nurse take?

A, Administer ibuprofen to clients.
B, Place the client in a side-lying position.
C, Apply a cool compress to the client’s abdomen.
D, Encourage the client to perform Kegel exercises.

44. A nurse in the provider’s office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid. Which of the following manifestations is the priority ?

A, Fetal heart tones 98/min
B, Maternal temperature 38.3dgree C (101dgree F)
C, foul smelling vaginal discharge
D, Amniotic fluid with meconium noted

45.A nurse on a postpartum unit is caring for a client who is breastfeeding and experiencing breast engorgement. Which of the following interventions should the nurse plan to implement to promote comfort for his client?

A, Have the client apply purified lanolin to her breasts.
B, Advise the client to avoid using a breast pump.
C,Provider the client with ice packs for her breasts.
D, Encourage the client to wear a loose- fitting bra.

46. A nurse is assisting with a prenatal class discussion about newborn safety. Which of the following understandings of the teaching?

A, “I should replace the batteries in my smoke detector twice per year”.
B, “I should use baby powder with each diaper change”.
C, “I should elevent my baby’s head on a cushion when she is sleeping”.
D, “I should set my hot water heater to 130 degrees Fahrenheit”.

47. A nurse is caring for a client who is postpartum and experiencing excessive vaginal bleeding. Which of the following medications should the nurse plan to administer?

A, Nifedipine
B, Terbutaline
C, Betamethasone
D, Oxytocin

48. A nurse is caring for a client who asks about the purpose of a papanicolaou test. Which of The following responses should the nurse make ?

A, “This test detects the presence of endometriosis.”
B, “This test determines your ovulation status.”
C, “This test detects the presence of cervical cancer.”
D, This test allows for the removal of uterine fibroids.”

49, A nurse is caring for a newborn whose mother had gestational diabetes. The newborn has a blood glucose level of 30mg =/ dL and is asymptomatic. Which of the following actions should the nurse take?

A, Administer glucagon.
B, Check urine for ketones.
C, Encourage additional feeding.
D, Recheck blood glucose in 4 hr .

50. A nurse in a clinic is reinforcing teaching about signs of breastfeeding with a client who has a 5-day -old newborn. Which of the following. Statements by the client demonstrate an understanding of the teaching?

A, “My baby will have at least six wet diapers every day.”
B, “I should be able to feel my baby swallowing during breastfeeding .”
C, I should expect moderate tenderness during breastfeeding.”
D, “My baby will have at least one bowel movement every day.”

52. A nurse is assisting in the care of a client who is in labor and whose membranes ruptured 6hr ago. Which of the following is an appropriate nursing intervention for this client?

A, Prepare for a forceps delivery.
B, Obtain consent for a cesarean birth.
C, Position the client supine.
D, Monitor for infarction.

53. A nurse in a prenatal clinic is collecting data from four clients. Which of the following findings is the nurse’s priority to report to the provider?

A, Varicose veins
B, Leukorrhea
C, Dysuria
D, Gingivitis
54. A nurse is reinforcing teaching with a client about the care of their newborn’s umbilical cord. Which of the following statements by the client indicates an understanding of the teaching?

A, “I should clean the cord with antibacterial soap with each diaper change.”
B, “I should keep the cord covered with my baby’s diaper.”
C “I should notify my baby’s provider if there is odor coming from the cord.”
D, ” I should expect some bright red bleeding from the cord until it falls off .”

55. A nurse is caring for a full-term newborn who is 1 day old.Which of the following laboratory findings should the nurse report to the provider?

A, Glucose 60 mg/dL
B, Platelets 225,000/mm3
C, Hgb9.5g/dL
D, WBC 10,000/mm3

56. A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level. Which of the following foods should the nurse recommend the client increase in her diest?

A, Long-grain rice
B, Peanut butter
C, Avocados
D, Yogurt

57. A nurse is reinforcing teaching about perineal care to a client who is 2hr postpartum and has an episiotomy and hemorrhoids.Which of the following statements by the client indicates understanding of the teaching?

A, “I will use the numbing spray prior to cleansing the area.”
B, “I will apply witch hazel pads after urination.”
C, “I will place a heat pack in the area several times a day.”
D, “I will remain in the sitz bath for 10 minutes.”

58. A nurse is caring for a client who is postpartum. The client is experiencing excessive vaginal bleeding and has a boggy uterus. Which of the following actions should the nurse take first?

A, Initiate fundal massage.
B, Administer methylergonovine0.2mgIM.
C, Encourage the client to empty her bladder.
D, Appy oxygen via non-rebreather mask at 8 L/min

59. A nurse in a provider’s office is collecting data from a client who is requesting a prescription for a transdermal contraceptive patch. The nurse should recognize that which of the following client findings is a contraindication for this method of contraception?

A, Weight 98kg (216lb)
B, BP 120/70 mm Hg
C, History of spontaneous abortion
D, Peptic ulcer disease

60. A nursing is planning to reinforce nutritional teaching with a client who is in her first trimester of pregnancy. The nurse should recommend an increase in which of the following nutrients to support an increase in maternal blood volume during pregnancy?
A, Vitamin E
B, Vitamin D
C, Iron
D, Calcium

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1. A 40-year old client who is 20 weeks gestation has had an amniocentesis. Which of these findings, if present, requires immediate intervention?
The client reports vagina bleeding
the client describes mild intermittent, Braxton Hicks contraction
the lab results revealed some chromosomal abnormalities
the amniotic fluid contains fine languo hair
2. The mother of a two month old tells a nurse that the baby is consuming 6 ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the babies diet is
too high in iron content
deficient in calcium
insufficient for the babies age and weight
too high in calories
3. The nurse give instruction to a client that needs to continue wound irrigations at home. Which of these actions, if observed by the nurse, would require further instructions?
The client irrigates the wound slowly and steadily, flushing away drainage and debris.
The client places a waterproof pad beside the wound before removing the dressing.
The client dons sterile gloves, and then opens a sterile syringe and solution container.
The client irrigates the would until the solution draining into the basin is clear.
4. When teaching a client that has been discharged with orders to continue with dressing changes, the nurse include which of these measures?
Demonstrating good hygiene technique.
Discussing surgical asepsis.
Describing the process of sterilization.
Demonstrating proper gloving technique.
5. A newly admitted client touches other clients on the head, speaks rapidly, wears several layers of clothing, and laughs continuously. Which of these manifestations should the nurse focus on first?
The clients’ dress.
The client’s affect.
Touching other patients on the head.
Rapid speech.
6. Which statement made by a client taking a diuretic, would the nurse recognize as indicative of the need for additional instructions?
“I eat one or two bananas every day.”
“I take all of my medications at bedtime, so I don’t forget them.”
“I weigh myself every day in the morning.”
“I will call my doctor if I have muscle weakness.”
7. A client has the following order for the regular insulin on a sliding scale:
Blood sugar 150-18 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units regular insulin
Blood sugar above 220 mg: Call healthcare provider
At 11 A.M., the nurse obtains a finger stick glucose of 198 mg. The only syringe on hand is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer?
40
0.4
4
0.04
8. The nurse is monitoring a client that taking acetylsalicylic acid 975 mg daily for adverse effects, which include
Increased serum calcium levels.
Increasing heart failure.
Loss of joint mobility.
Occult blood in the stools.
9. When discussing the effects that drugs have on the brain, it is important for the nurse to understand whether these drugs enter the brain through which of these factors?
Electrical stimulation.
The brain tissue.
The blood-brain barrier.
Glucose-carrying cells.
10. The client is taking sublingual nitroglycerin. Which of these statements, if made by the client, indicates a need for additional teaching?
I know I should call my doctor if I feel lightheaded.
If I feel burning under my tongue, I should discontinue this medicine.
If the pain persists, I can take this medicine every five minutes for up to three doses.
I will immediately report a headache to my physician.
11. All of these patients have an order for IV morphine sulfate. Which of these clients would the nurse question the physician’s order of IV morphine?
A 78-year-old client that has sustained a hip fracture.
A 17-year-old client that has a head injury and is in severe pain.
A 32-year-old client that has mastectomy two days ago.
An 8-year-old client in sickie cells crisis that has a temperature of 160 (38 ).
12. The client is receiving a medication that is nephrotoxic. The nurse would hold the next schedule dose of medication if the client has which of the following laboratory results?
Decreased serum creatinine level.
Elevated serum bilirubin level.
Elevated blood urea nitrogen (BUN) level.
Decreased serum glutamic oxaloacetic transaminase (SGOT) level.
13. The client that is taking warfarin sodium develops a nosebleed. Which of these medications would the nurse prepare to administer?
Epinephrine.
Phytonadine.
Enoxaparin.
Protamine sulfate.
14. A client is to receive intermittent intravenous antibiotics in 100 mL D5W over one hour. When setting the infusion pump, a nurse would regulate the volume to be delivered ay which of these rates.
100 mL
200 mL
150 mL
50 mL
15. The client that underwent surgery is having pain and ask for pain medication. Before administering the medication, the nurse checks the client’s vital signs. Assessment data reveal: pulse = 100/minute, respirations = 32/minute and BP =134/92 mm Hg. Which of these actions would the nurse take?
Recheck the client’s vital signs in 30 minutes.
Give the pain medication to the client.
Ask if the client is feeling anxious.
Check the client’s dressing for bleeding.
16. The client is receiving enteric-coated medication. Which information would the nurse include in the client instructions about the medication?
The medication melts after being inserted into a body cavity.
The medication dissolves quickly if placed under the tongue
The medication needs to be shake thoroughly before administering
The medication dissolve when it reaches the small intestine.
17. Which of these responses, if made by the client, would indicate to the nurse that the client has given informed consent?
“I understand, but exactly will be done?”
“I realize the scar will be visible for a few weeks.”
“I’m in so much pain, I’ll sign anything.”
“My family wants me to go through with this.”
18. When the client that has acute postoperative pain receives morphine, the nurse would monitor the client for which of these conditions?
Respiratory depression.
Increased urinary output.
Constipation.
Hypertension.
19. Which postoperative complication in the first hour after surgery requires immediate intervention?
Serous draining on the dressing.
Dehiscence of a wound.
Vomiting.
Swelling of an extremely under a cast.
20 A client has a head injury is drowsy and lethargic and has clear nasal discharge. Which action would the nurse take?
Cover the nares with sterile gauze.
Obtain a specimen of the drainage for culture and sensitivity.
Test the drainage for glucose.
Cleanse the nostrils with sterile saline solution.
21. Which action would the nurse take initially if the client that is diagnosed with diabetes mellitus develops tremors and ataxia?
Measure the client’s blood sugar level.
Administer a concentrated form of glucose to the client.
Administer a prn dose of insulin.
Measure the client’s urine for ketones.
22. Which outcome criterion is appropriate for the client that has a nursing diagnosis of ineffective airway clearance?
Pulse oximetry level of 80%
Frequent coughing throughout the day.
Absence of wheezing throughout the lung fields.
Clear lung sounds on auscultation.
23. The client that has Acquired Immune Deficiency Syndrome (AIDS) is admitted to the hospital with a diagnosis of pneumocystis carinii pneumonia. When planning care for the client, the nurse would include which of these priority nursing measures?
Encouraging increased activity.
Promoting adequate sleep patterns.
Preventing pulmonary embolism.
Maintaining adequate oxygenation.
24. Which of these assessment findings in a client should a nurse recognize as indicative of early manifestation of hypoxemia?
Pallor.
Bradycardia.
Hypotension.
Restlessness.
25. A 40-year-old primigravida is hospitalized for severe pregnancy-induced hypertension (PIH). Which of these nursing actions should be accomplished first?
Start an IV for oxytocin administration.
Administer anti-hypertensive drugs.
Call the lab to draw blood.
Record baseline vital signs.
26. A 2-year-old child is admitted to the hospital with nephrotic syndrome. When admitting the client to the hospital, the nurse is most likely to obtain which statement from the client’s parent?
The child was treated for impetigo a couple weeks ago.
The child cries when voiding.
The child has had swollen eyes lately when waking up in the morning.
The child has lost weight over the last few days.
27. A client is admitted to the pediatric intensive care unit for observation of congestive heart failure secondary to viral cardiomyopathy. Which assessment finding is the nurse most likely to see?
Flushed face.
Sunken fontanel.
Weak peripheral pulses.
Cyanosis in the lower extremities.
28. The physician prescribes prostaglandin (PGE2) gel for a client being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?
The client’s uterine contraction pattern is enhanced.
The client’s cervix is softened.
The client’s cervix is dilated.
The client’s uterus is softened.
29. When assessing a group of children, a nurse should recognize which child is at increased risk of developing a cute glomerulonephritis?
A 4-year-old child who had a streptococcal infection a week ago.
A 5-year-old child who has recurrent enuresis at night.
A 3-year-old child who has multiple urinary tract anomalies.
A 6-year-old child who had chicken pox infection two weeks ago.
30. Which assessment finding present in a primigravida, indicates that the client is experiencing true labor?
There is a progressive increase in effacement and cervical dilatation.
The pains are felt in the lower abdomen, back and groin.
The Braxton-Hicks contractions have become stronger and more frequent.
There is an increased of white mucus discharge.
31. Which of these fetal heart rate (FHR) patterns would indicate to a nurse that a bib-stress test (NST) is reactive?
The FHR decreases 15 beats/minute would remains decreased for 15 seconds.
The FHR remains unchanged with maternal movements.
The FHR does not change during fetal movements.
The FHR increase 15 beats/minute and remains elevated for 15 seconds.
32. A pregnant client tells a nurse that she thinks she has developed an allergy because her nose is often very congested. Which of these responses should the nurse make?
“This is not normal; perhaps you developed a chronic respiratory infection.”
“It is normal; the congestion is due to one of the hormones of pregnancy.”
“It is not unusual to develop allergies during pregnancy.”
“I will ask the doctor to prescribe a nasal decongestant for you.”
33. Which of these actions should a nurse take prior to giving diet instructions to pregnant clients?
Assess what the clients eat by taking a dietary history.
Instruct the clients to continue eating a normal diet.
Give the clients a list of foods so they can better plan their meals.
Emphasize to the clients that importance of limiting salt intake.
34. The mother of an 8-month-old child proudly tells the nurse in the well-baby clinic that the child eats very well. Laboratory reports confirm that the child has iron deficiency anemia. Considering this diagnosis, the nurse should give priority to which action?
Ask the mother if the child has been eating non-food substances like paint chips.
Tell the mother that the child will probably require a blood transfusion.
Refer the mother to the social worker for assessment of parenting abilities.
Provide the mother with a list of age-appropriate iron rich foods.
35. A client visits the clinic when she is 28 weeks pregnant. She says, “I usually swim twice a week in an outdoor pool. I guess that’s not too good an idea now.” Which response, if made by the nurse, is most appropriate?
“The chlorine used to purify the water may be hazardous to the developing fetus.”
“After the eighth month, this activity usually causes negative pressure on the uterus.”
“This activity can probably be continued throughout pregnancy.”
“The temperature of the water should be at or slightly above normal body temperature.”

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Oxygen Therapy

Many of the clients you encounter will require the use of oxygen (O2) as part of their treatment. Oxygen is a gas that is vital to life— without it, tissue cells can die in four to six minutes. With proper handling and storage techniques, it is a safe and effective therapy.

How is it decided that a client requires oxygen?

Oxygen must be prescribed by a physician and is therefore treated like a drug: the PSW may not administer Oxygen; however, they may assist clients with their therapy. If the PSW should have any questions or concerns, they should immediately notify their supervisor.

In order to decide whether or not a client will require Oxygen therapy, several factors must be considered. The first thing is the client’s oxygen saturation (you might hear this called the “O2 sat”). A special monitor is attached to a client’s finger or toe, and a sensor measures how much oxygen is in the blood (how much oxygen has saturated the blood). This measurement is read as a percentage. Most healthy people have an O2 sat in the high nineties to 100 range. Anything consistently below 90% is usually a sign that the client will need O2 therapy.

Chronic breathing illnesses causing lung damage, like Bronchitis, or COPD (chronic obstructive pulmonary disease), as well as cigarette smoking, are major causes of low O2 sats. These clients are usually placed on long-term, continuous O2 therapy.

Sometimes people are admitted to hospital with a breathing crisis, such as pneumonia or another respiratory infection. Their O2 sat would be low and O2 immediately given. This is not considered long term therapy because once the crisis is over, their O2 sat should recover and, therefore, the need for oxygen will be gone.

It is important to remember that every client is different and will be prescribed oxygen therapy on an individual basis. The PSW’s observations and input regarding the client’s status and how well they manage their treatment are key factors in the successful use of O2 therapy.

What is the difference between intermittent and continuous therapy?

Intermittent therapy is used only when the client’s symptoms require it. An example of this might be when a client becomes short of breath after activity. At rest, they don’t require O2. However, the activity will increase their need for it.

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Continuous therapy is used when clients require O2 24 hours a day. Usually these clients have a chronic type of respiratory illness that results in a low O2 saturation. They will generally feel tired, sluggish, and have a low activity tolerance— all of these should stabilize as treatment progresses.

Always remember that the client with breathing difficulties may have a tendency to be somewhat anxious, which can, in turn, increase shortness of breath! Many state they feel like they’re “suffocating,” or that something bad is going to happen to them. Oxygen therapy can be very reassuring to them. Support from the PSW is a vital part of the therapy. Helping to keep calm, staying with them, and making sure they are using the equipment safely are part of the PSW role.

Who decides how much oxygen a client receives?

Again, because oxygen is considered a drug, the physician not only decides what type of therapy the client receives, but also how much.

Oxygen is delivered at a specific flow rate. This flow rate is measured in liters per minute (L/min). All oxygen is turned on, and then the flow meter is dialed to the appropriate number (e.g. a client is prescribed 2L/min per NP). Clients and family members are instructed on how to use and regulate the flow meter.

It is important to understand that the PSW’s role is only to assist with this aspect of oxygen therapy. The PSW should never adjust or prescribe a different flow rate. Many clients and family members will ask the PSW to do this for a good number of reasons. They might say, “but I’m so short of breath. If the 2L isn’t helping me, shouldn’t I try the 3L? It’s not much more!” If the family or PSW has concerns regarding the client’s breathing status, they should notify the doctor and nursing supervisor immediately.

How is oxygen supplied to the client?

Several different methods are used. In some facilities, there will be a central storage area for oxygen, and the users simply plug their O2 tubing into a wall outlet. This is not practical in a smaller facility or in a private home.

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Portable oxygen tanks (cylinders) are an option when your client is mobile. Large tanks are available for use inside the home/facility. Long, extendable tubing is attached so that the client may freely move about the area. Caution should be used to avoid tripping over the tubing!

When clients wish to venture to another location outside of the home/facility, smaller, portable cylinders are available. These cylinders may be moved on a cart or carried in a special carrying device. They don’t last as long as the larger cylinders, but do give clients the freedom to travel, keep appointments, and escape the four walls of their home! These small cylinders are also handy in an emergency situation, or whenever a client is being moved from one area to another.

It is important to note that the oxygen we have been discussing has been in the form of gas. Liquid oxygen is also available. Large canisters (similar to tanks) are used to store the cold (-294 degrees F) liquid oxygen. The client and family may be trained to fill smaller, portable canisters from a larger, main unit. The O2 supplier would be scheduled to refill the main unit on a regular basis.

Perhaps the most cost-efficient and commonly used system in the community is the oxygen concentrator. It is an electrical device that takes room air, extracts the oxygen, and delivers it to the patient. Since it is powered by electricity and is not portable, the client should have an alternate source of O2 available (such as a canister of O2). The “backup” system could be used in the event of a power failure, or if they wish to leave the home and must keep their oxygen on. Lengthy O2 tubing could be attached to the concentrator to allow the client mobility within their home.

Some clients may be concerned about the added cost of electricity on their monthly hydro bill. Using the current rate, the cost for one client on 24hr/day O2 concentrator therapy would amount to approximately $260.00 per year, or approximately $21.60 per month. This can be a burden to someone who is living on a fixed income. The Assistive Devices Program is designed to help clients cope with the added financial burden by providing partial or full financial assistance.

How does the oxygen get from the source to the client?

Before the oxygen actually reaches the client a couple of things must happen first. Think about the respiratory system: what happens to the air you breathe before it gets in your lungs? First, the little hairs in your nose and bronchus filter out many of the microscopic particles of dirt and other materials. Second, the air is warmed and moistened by passing over the mucous membranes that line the structures of the respiratory system.

Since we are not using “room air” in most cases, the oxygen the client receives has no real need to be filtered, because the oxygen concentrator will filter the room air before delivering it to

© N A C C 2 0 1 7 V . 4 Section IV. Module 12. Health Conditions 4 | 11
the client. However, the oxygen remains very dry and needs to have some humidity added to it. This procedure is usually done by attaching a humidifier (“water bottle”) to the oxygen source before the oxygen is sent through the tubing. This way, the client receives oxygen that has already been moistened.
Note: It is important to remember that even though this “humidity” has been added, O2 can still be very drying to the client’s mucous membranes. This may result in complaining of a dry nose, sore nose, nosebleeds, or a dry mouth. It is important that these complaints be listened to: if we ignore them, the client is less likely to be compliant with their treatment. Dealing with these problems will be discussed later on in this assignment.

There are two main ways to get the oxygen to the client. The first method is by using a face mask. This mask should cover both the nose and mouth. Small holes on the sides of the mask allow CO2 (Carbon dioxide – a waste material from breathing) to escape when the client breathes out, and room air to enter when the client breathes in.

The face mask has a tendency to be uncomfortable for some clients. Some people find the pressure from the mask constantly on their skin very bothersome. Others find that having the mask on their face feels as if they are going to suffocate. The mask will also interfere with a person’s eating, drinking, and conversation. It is beneficial for clients who are on a high-flow rate of O2.

In some cases, a special colour-coded plastic device at the base of the tubing will determine the percentage of O2 that the client receives. This will be ordered by the physician and is not to be determined by the PSW. The PSW’s role is to follow the client’s normal routine for oxygen use. If this routine changes, they should notify their supervisor.

The second method used in nasal cannula: these are often referred to as nasal prongs, NP for short. This is the most widely used method. This device will look like a very long piece of oxygen tubing with two little “prongs” sticking out. These two prongs will curve slightly and should be placed in the nostrils (nares) so that the prongs point downward— otherwise, it will be very uncomfortable and irritating for your client and may hamper the flow of oxygen. The tubing is then placed behind the ears to hold the prongs in place. A small, sliding plastic “holder” can be slid up the neck portion of the tubing to secure the prongs in place, much like a hat that fits under the chin. Some clients prefer the tubing to be placed behind their head, going down their back: this would be most comfortable for clients who are immobile.

Nasal cannula allow a great deal more freedom than a mask. A client would be free to wander, eat, drink, talk, and complete their ADLs. By attaching one or more pieces of extension tubing to the cannula, you can allow the client to go further distance. Caution should be used with the use of canes and walkers— you don’t want them to get tangles in the tubing! Tubing may be pinned or taped to the client’s clothing to keep it free of kinks and from getting in the way.

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Although cannulas are used with lower flow rates of O2, clients may still complain of the drying effects. They may also complain of irritation from the tubing on the face or behind the ears. This can be dealt with by gently padding the area with some gauze.

It is important to understand that although clients are prescribed continuous O2 therapy, they will not die if they go without it for a short while. Many clients will have their face mask or nasal prongs fall off while they are asleep and not notice until a couple of hours later. Removing the oxygen while they dress or bathe is generally not a problem either. Just remember that some clients get extremely anxious, and the PSW should be there to support and reassure them.

What do I need to know to handle oxygen safely?

The greatest risk that O2 use presents is that of fire. Although O2 itself will not burn, it will help or accelerate other materials to do so. In fact, a fire will generally not continue without the presence of oxygen. Listed below are some of the safety measures that can be used by the client/family/PSW:

1. Any flammable materials and/or heating sources should be kept a minimum of 5-10 feet away from O2 equipment. Such items may include: curling irons, heating pads, hair dryers, electric blankets, and electric razors.

2. Do not attempt to lubricate equipment. Leave this for the professionals! Oil and grease based lubricants easily explode. Also, aerosolized sprays often contain particles that can be dangerous if inhaled by a client with breathing difficulties.

3. Avoid the use of aerosol sprays around oxygen equipment. These cans are under pressure and can easily explode. Also, aerosolized sprays often contain particles that can be dangerous if inhaled by a client with breathing difficulties.

4. Petroleum based products should be avoided. These include: Vaseline (petroleum jelly), Nivea cream, or any combination cream that contains petroleum. Clients may wish to use these products to moisturize areas left dry and irritated by the use of O2 equipment. Water based products can be used as safe alternatives: Muko, KY Jelly, or Secaris can be used inside a dry nose instead of Vaseline. Vaseline Intensive Care Lotion or a similar product may be used on other areas.

5. Keep all equipment in a well-ventilated area. Doing this will prevent an accumulation of O2 that could be a fire hazard

6. Liquid oxygen units should always be kept airtight. This will prevent an accumulation of O2 that could be a fire hazard.

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7. Oxygen tubing should never be obstructed or “kinked.” Never place the tubing underneath carpeting, furniture, blankets, or clothing as this may allow O2 to accumulate, causing a fire hazard.

8. Use caution when transporting O2. The oxygen supply company should be consulted on how to safely “move” O2 cylinders and tanks: this should be reviewed when the O2 therapy is initiated. The tanks/cylinders should not be stored in an area without ventilation, such as the trunk of the car.

9. Avoid smoking in the area where the oxygen is being used. Smoking near O2 poses an EXTREME risk for fire, explosion, or injury. The following are some situations you may encounter:

a. Client smokes well away from O2 equipment that has been turned off. There is no real immediate hazard with this, but it is possible that the client may forget to turn off the O2 at some point. Be sure to notify your supervisor and document carefully.

b. Client smokes with O2 on. This is EXTREMELY dangerous! If the client is doing this when you arrive for your visit, you MUST ask them to put out their cigarette, etc. If they refused your request, you must leave the premises for your own safety. Your supervisor must be notified IMMEDIATELY!

c. Client who is cognitively impaired and states that they still smoke while they are on O2 therapy. As long as the client is not doing this while you are visiting, it is safe for you to stay. However, safety rules should be reviewed with the client and their family as well as notifying your supervisor.

These guidelines also apply to family members and visitors in the home. It is suggested that if family or visitors wish to smoke, they do so at least 10 feet from the oxygen— even better would be to go outside. A warning sign may be obtained from the oxygen supply company and posted on the door to warn all visitors that oxygen is in use.

When it comes right down to it, oxygen safety is mostly about common sense. If you are ever in doubt about how to handle a situation, contact your supervisor or even the oxygen supply company and ask its advice. Educate yourself about safe handling practices and you will be able to pass their knowledge along to your clients.

This learning package was designed to help you become familiar with the basics of oxygen therapy. If possible, you should try to get some “hands-on” experience while completing your

© N A C C 2 0 1 7 V . 4 Section IV. Module 12. Health Conditions 7 | 11

clinical rotation. Be certain to let your instructor and the clinical staff know that you are interested so they will be on the lookout for learning opportunities for you.

The following pages contain your oxygen therapy assignment and are to be completed outside of classroom time and handed in on the due date given by your instructor. Please keep this reading assignment in your notes for future reference.

© N A C C 2 0 1 7 V . 4 Section IV. Module 12. Health Conditions 8 | 11
Oxygen Therapy Hand-in Assignment /30

1. Define the term oxygen saturation. (1 Mark)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. List two causes that can contribute to a low O2 sat reading. (2 Marks)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. Define the term “continuous oxygen therapy” and explain why it is beneficial for people with chronic breathing difficulties. (2 Marks)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

4. Why is humidity added to the oxygen source before it is breathed by the client? (1 Mark)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

© N A C C 2 0 1 7 V . 4 Section IV. Module 12. Health Conditions 9 | 11

5. You are assigned to Mr. Cy Hendriks to provide assistance with ADLs. This client has emphysema and there is oxygen equipment in the home. While preparing to assist him with his morning bath, you notice that he smells of cigarette smoke, although you don’t notice any cigarettes or ashtrays nearby. How would you proceed with this situation? (3 Marks)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

6. List two possible hazards that occur when clients/family members smoke near oxygen. Describe two actions the PSW could take to avoid these hazards in the workplace and ensure their safety as well as the client’s. (4 Marks)

Hazard one______________________________________________________
_______________________________________________________________

Hazard two______________________________________________________
_______________________________________________________________

Actions_________________________________________________________
_______________________________________________________________

7. What is the PSW’s role regarding the client’s use of oxygen therapy? (1 Mark)
_____________________________________________________________________
_____________________________________________________________________

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8. During your home visit with Mrs. Emma Rock, she complains that the nasal cannula she has been wearing is irritating her cheeks and behind her ears. What are two ways the PSW could assist her? (2 Marks)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

9. Name two products that should be avoided when a client is using oxygen. For each product name a safer alternative. (4 Marks)

Product to be avoided Alternative product

10. List three ways that oxygen may be supplied to the client. (3 Marks)
______________________, ____________________, ____________________

11. When clients have dyspnea (difficult or painful breathing), they are often anxious and upset. What are two interventions the PSW could do to help reduce their anxiety? (2 Marks)
________________________________, _______________________________

12. Name three breathing illnesses that may require the client to use oxygen on either a temporary or continuous basis. (3 Marks)
____________________, ____________________, _____________________

13. Your client complains he is SOB and asks you, his PSW, to turn their oxygen up “just a bit.” The oxygen is currently running at the prescribed amount of 3L per minute. How do you respond to your client? (2 Marks)
_______________________________________________________________
________________________________________________________________

© N A C C 2 0 1 7 V . 4 Section IV. Module 12. Health Conditions 11 | 11

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1.
Question:
During a session, the PMHNP asks a patient with a history of sexual
abuse to recall the relationship she had as a child with her parents. The patient
responds by saying she has a headache and her stomach hurts, and starts talking
about her physical ailments. What is the appropriate response by the PMHNP?
2.
Question:
A PMHNP is assessing ego functioning of his 40-year-old patient by
asking what she feels is the cause of her problems. She attributes her problems to
her overprotective parents not letting her have enough freedom growing up. Based
on her answer, the PMHNP is testing _____________.
3.
Question:
A 28-year-old male patient is experiencing distress related to the
workplace. What might the PMHNP ask to assess affective development?
4.
Question:
The PMHNP has been treating a 15-year-old patient with a history of
abuse and neglect. Thirty minutes into their therapy session the patient jumps up
and begins to pace around the room. Utilizing Socratic dialogue (SD) the PMHNP’s
best action would be to:
5.
Question:
The PMHNP understands that anxiety and depression are two
disorders in which their symptoms may overlap. When discussing this, you explain
that the autonomic nervous system is activated and further helps distinguish anxiety
symptoms by making the following points:
6.
Question:
A PMHNP is taking a history and wants to assess how the patient
copes with adversity. To do so, the therapist asks questions about the patient’s belief
system. What would be an appropriate question to ask?
7.
Question:
A PMHNP is caring for a 21-year-old woman who is suffering from
anxiety and is having difficulty managing stress. Which of the following would be an
appropriate step by the PMHNP?
8.
Question:
Your patient is a 65-year-old male who has a strained relationship with
his son and daughter. His children refuse to participate in a family session. The
PMHNP asks the patient to draw his family genogram as a next step to
_______________.
9.
Question:
A new patient has been … of the limits of confidentiality, and has …
consent forms. No consent, however, has been obtained for voluntary “Release of
Information.” The patient is 20 years old and still lives at home with his parents. He
is being … for depression, which he attributes to the trouble he’s had finding
employment.
True or false: If the patient’s mother calls the PMHNP to check up on her son to see
how he is doing, the therapist is required to protect patient confidentiality and not
disclose information.
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10.
Question:
The PMHNP is working with an adult patient who has somatic
complaints … by a history of childhood abuse. As part of the therapeutic process,
what does the PMHNP do to assess and organize a trauma history?
11.
Question:
The PMHNP is caring for a patient who has acute stress disorder after
experiencing a traumatic event 1 week prior. The PMHNP wants to begin with a
therapeutic framework that follows the adaptive information processing (AIP) model.
What is the priority action for the PMHNP to take?
12.
Question:
A patient who has borderline personality disorder is meeting with the
PMHNP. When asked about future goals, the patient responds, “I’d like to go back to
school to do what
you
You know, talk to people all day about their problems. It
seems pretty easy.” How does the PHMNP respond to the client in a way that is free
from any stigmatizing beliefs or judgments?
13.
Question:
The PMHNP is treating a 35-year-old male officer in the military. He
discloses that both of his parents are deceased and that he loved them. However, he
says that he had feelings of inadequacy because his parents held him to a standard
that he could never achieve. He went on to say that nothing he did ever felt good
enough. The PMHNP assesses that this patient has perfect creases in his uniform
with no strings or tags out of place; she also notices that he has perfect posture and
questions him about ritualistic behaviors. She suspects that this patient has
maladaptive responses to the expectations placed on him as a teenager and young
adult. Which statements made by the patient would verify the PMHNP’s suspicion?
14.
Question:
During a therapy session with an 18-year-old female the PMHNP
learns that she has lived in six different foster homes in the last 24 months. She
states that her mother is in a correctional facility for drug abuse and prostitution.
During the assessment, the PMHNP notices multiple superficial cuts to each wrist.
The patient appears tearful, withdrawn, and never makes direct eye contact. The
PMHNP believes that this patient may have feelings of insecurities as well as
abandonment issues and is aware that which diagnosis is likely possible?
15.
Question:
An 11-year-old patient has been exhibiting low self-esteem at school
and acting out. According to Maslow’s hierarchy of needs, which of the following
questions would best be addressed first by the PMHNP?
16.
Question:
When completing this exam, did you comply with Walden University’s
Code of Conduct including the expectations for academic integrity?
17.
Question:
The PMHNP has a session with a patient who was injured and
traumatized from an explosion at the industrial plant where he used to work. During
the session, an outside noise startles the patient and he experiences a flashback of
the loud
boom
from the explosion. The PMHNP witnesses the patient present with
anxiety and belabored breathing. What is the appropriate action of the PMHNP?
18.
Question:
The PMHNP is working with a veteran who has posttraumatic stress
disorder (PTSD). The PMHNP believes that dual awareness will be beneficial in
allowing the patient to focus on the here and now. What strategies can the PMHNP
use to develop dual awareness in the patient?
19.
Question:
A patient named Steve is seeking therapy to get help with his home
situation, stating that he has been stressed since his mother-in-law moved into the
house. What can the PMHNP do to assist the patient in constructing a narrative?
20.
Question:
The PMHNP is meeting with a 38-year-old … , single mother who has
been seeing the PMHNP for anxiety and anger management. During one of the
sessions, the patient tells the PMHNP that she is having a problem getting her child
support payments from her ex-husband, which is triggering increased anxiety and
anger, which she admittedly takes out on her children. How does the PMHNP
respond in a way that upholds the supportive psychodynamic psychotherapy
approach?
21.
Question:
When a PMHNP is seeing a patient for the first time, what is an
important step to assure that the patient and provider understand the limits of their
discussion?
22.
Question:
During cognitive behavioral therapy (CBT), a 64-year-old male patient
states, “I get so frustrated sometimes and I just blow up at everybody!” Which
response by the PMHNP demonstrates translation of Socratic dialogue (SD)?
23.
Question:
During a therapy session the patient is … how she currently deals
with stress, and she says, “Well, I don’t. I just let it build and build.” The PMHNP
responds by asking how well this has been working out for her. The patient states,
“Well, to be honest, it just feels like I’m drowning, you know what I mean.”
Illustrating idiosyncratic meaning, the PMHNP responds with:
24.
Question:
The PMHNP is working with a school-aged child who has been … with
depression. The child has attended several sessions with the PMNHP, but recently
presents with avoidant behavior by showing increased distress and being late to
sessions. What approach does the PMHNP need to employ with the child to continue
making therapeutic progress?
25.
Question:
The PMHNP is working with a patient who is living in poverty and
abusing substances. According to the treatment hierarchy framework, what needs
does the PMHNP need to attend to first?
26.
Question:
During cognitive behavioral therapy (CBT), a 64-year-old male
patient, states, “My wife hates me! She’s just waiting for me to die.” Using Socratic
dialogue (SD) the PMHNP demonstrates understanding of analysis when she
responds:
27.
Question:
The patient is a 56-year-old female patient … with panic disorder and
reports symptoms that include heart palpitations, frequent trembling, and feelings of
choking in stressful situations. What special consideration does the PMHNP make?
28.
Question:
A 62-year-old patient has been … with borderline personality disorder.
Upon assessment, the PMHNP learns that he
participates in spending sprees and
occasional binge eating, accompanied by rapid changes in self-image. Which
evidence-based psychotherapeutic model does the PMHNP identify as effective and
beneficial?
29.
Question:
The PMHNP is meeting with a new patient who is a young veteran
back from serving two tours overseas. When reviewing the patient’s health history
file that was sent from the VA, the PMHNP learns that several months ago, the
patient was … with PTSD, but never followed up with treatment for it. After a
comprehensive mental health assessment, the PMHNP confirms the PTSD diagnosis
and understands that which therapeutic approach will be the most effective as a
first-line treatment modality?
30.
Question:
The PMHNP is working with a patient who experiences anxiety around
her parents that later leads to poor impulse control. What will the PMHNP do to
employ psychodynamic psychotherapy properly for this patient?
31.
Question:
The PMHNP is treating a patient with a substantial fear of feeling … in
(claustrophobia). Thus, the patient will not get into an elevator. The office where he
works is on the 10th floor and this requires that he walk up and down the stairs in
the morning and evening to get to his office. With permission from the patient, the
PMHNP is beginning systematic desensitization to address the patient’s need to use
the elevator. What is the PMHNP’s best plan of action?
32.
Question:
True or false: If after a third round of processing … by stabilization, a
patient has increased anxiety that requires further interventions aimed at
stabilization, the therapeutic relationship can no longer successfully provide
therapeutic change.
33.
Question:
One of the strategies the PMHNP wants to try includes sleep
restriction. What will the PMHNP suggest to follow sleep restriction therapy?
teach the safe-place exercise to create a feeling of calm. In order to walk the patient
through the exercise, the PMHNP first says:
47.
Question:
A 41-year-old male patient is meeting with the PMHNP and reveals
that he is homosexual. He begins telling the PMHNP about his feelings as a
homosexual, middle-aged man. The PMHNP nods understandingly. Before long, the
patient asks, “Are you gay? Are you married? Do you have kids?” What is the best
response by the PMHNP?
48.
Question:
In your office, you see a 58-year-old patient with PTSD who reports
having nightmares, making it impossible for her to sleep. What recommendations
based on principles of sleep hygiene will the PMHNP make?
49.
Question:
The PMHNP is caring for a patient with borderline personality disorder.
Using a psychoanalytic psychotherapy approach, the PMHNP attempts to intensify
the patient’s transference to enhance emotional processing by:
50.
Question:
The PMHNP is working with a patient who seems … with the
therapeutic relationship. The PMHNP invites the patient to discuss her feelings
regarding the PMHNP openly and honestly. It becomes clear to the PMHNP that they
are experiencing an alliance rupture. How does the PMHNP repair the therapeutic
alliance?
51.
Question:
The PMHNP has been assisting a shy and timid 23-year-old male
patient struggling with esteem and self-concept issues. Over the weekend, this
patient was given the task of completing an exercise that would usually cause him
distress and shame, also called a shame-attacking exercise. The PMHNP determines
that this task has successfully been achieved when the patient states:
52.
Question:
The PMHNP is working with a 43-year-old male patient who develops
idiosyncratic transference over weeks of therapy. The best way for the PMHNP to
respond to this patient is to ___________
:
53.
Question:
A PMHNP is treating a 50-year-old patient who suffers from
depression. When he was growing up, he was often responsible for taking care of his
three younger siblings. Since then, the patient puts other people’s needs before his
own. Based on this information, the PMHNP would conclude that his interpersonal
style is __________.
54.
Question:
The PMHNP is working with a patient who has insomnia and battles
going to sleep. The patient reports consistent self-defeating behaviors, and hates
trying to go to sleep. Which action made by the PMHNP demonstrates the use of a
paradoxical intervention?
55.
Question:
During a clinical assessment of a 15-year-old patient, the PMHNP
asks, “How can I help you?” The patient answers by saying, “Honestly, I don’t really
think I need any help.” Which of the following is the most appropriate response by
the PMHNP?
56.
Question:
The PMHNP is meeting with a 42-year-old man with depression
brought on by the recent passing of his wife. As he describes the circumstances
surrounding his late wife’s death, the PMHNP begins to feel sad. The sadness lingers
for several hours, and the PMHNP finds it difficult to focus on other patients for the
rest of the day. What is the most appropriate explanation for the reaction that the
PMHNP is experiencing?
57.
Question:
You are seeing a 29-year-old widow whose husband recently died
overseas while serving his country in the military. She has been mourning the loss of
her husband for several months, and continues to grieve. She refuses to go to group
grieving sessions, but reports that she is still able to go to work and her fitness
classes sometimes, and even makes attempts to stay social. She says, “Sometimes
it’s like he’s not even gone. Other times it feels like it’s been an eternity since I’ve
seen him. It’s hard to talk about this type of stuff with my girlfriends, especially
since all of their husbands are still alive.” The PMHNP understands that it is
appropriate to employ which therapeutic principle?
58.
Question:
A PMHNP’s patients have already … confidentiality agreements,
including limits that will be imposed on confidentiality. Months later, the state’s laws
have changed that affect confidentiality promises the PMHNP has already made.
What is an appropriate step for the PMHNP to take after finding out this information?
59.
Question:
A 35-year-old patient has been seeking treatment for depression for
several months. The PMHNP does an assessment to see if processing has led to
adaptive change. The patient’s self-references are positive in relation to past events,
work is productive, relationships are adaptive, and there is congruence between
behavior, thoughts, and affect. Based on this information, the PMHNP decides the
patient ____________.
60.
Question:
The PMHNP meets with a 47-year-old male patient who is fearful of
leaving the house after having witnessed his neighbor getting run over by a car.
When the PMHNP asks why he is afraid to leave his house, the patient replies,
“Because another accident might occur.” Which cognitive behavioral therapy (CBT)
strategy does the PMHNP employ?
61.
Question:
The PMHNP is working with a patient who experiences abreactions
when discussing …feelings of his sexual abuse as a child. What can the PMHNP do to
manage the patient’s intense emotional reactions?
62.
Question:
A 16-year-old female patient has had a stable therapeutic relationship
with the PMHNP for several months. The PMHNP notices what appears to be fresh
cigarette burns on the patient’s arm. When asked, the patient admits to this self-
injurious behavior. Although the patient is still depressed, her mood seems to be
somewhat better this week. True or false: The PMHNP would most likely consider this
patient stabilized and ready to move to Stage II.
63.
Question:
The PMHNP is assessing a patient who grew up in a foster home
because she was … and abused by her birth parents at a young age. The patient
admits to having difficulty forming and maintaining relationships throughout her life.
Understanding maladaptive schemas, which statement does the PMHNP predict that
the patient is likely to make?
64.
Question:
The PMHNP is caring for a patient with dissociated self-state that the
PMHNP identifies as being associated with traumatic experiences in the patient’s
past. What approach does the PMHNP use with the patient that is crucial to the
psychodynamic therapy process?
65.
Question:
When conducting an initial assessment, a PMHNP has finished
conducting a mental status examination with 10 minutes left in the session. The
patient is distressed and would like to continue sharing her personal history.
True or false: An appropriate response that the PMHNP might tell the patient is, “I
understand that you are upset. [Summarizes … , treatment recommendations, and
follow-up plan.] We can continue the conversation next week. How does this time
next Monday work for you?”
66.
Question:
True or false: A PMHNP may ask his patient to describe her
relationship with her father, both as a child and now, in order to assess interpersonal
style.
67.
Question:
The PMHNP is working with a patient who … her father pass away
after suffering for several months from terminal cancer. The PMHNP sees this as a
traumatic event. The patient reports sometimes feeling out of touch with
surroundings; almost as if things feel like a dream. “Sometimes that sensation
lingers for a while,” the patient says, “and other times I snap out of it quickly.” What
does the PMHNP infer about the condition based on psychotherapy concepts for
trauma?
View answer and explanation
68.
Question:
A PMHNP has been working with a young female patient who suffers
from depression to change self-defeating behaviors. By creating a presence of
acceptance and using good listening skills, the PMHNP’s overall goal is to __________.
69.
Question:
An initial evaluation reveals that an 11-year-old patient has moved to
a new school after her parents’ recent divorce, and is having trouble making friends.
The patient has normal mental status and exhibits appropriate behavior. What is the
most appropriate scale for the PMHNP
to use to get more information?
70.
Question:
When the patient comes into the office, she says, “I just saw a friend
of mine out in the waiting room. What’s wrong with him?” The PMHNP says, “He’ll be
fine. He has mild depression.” Which of the following statement is correct … to
confidentiality rights?
71.
Question:
An elderly patient in a nursing home has been losing interest in
activities and now refuses to leave his room. After a physical exam, he is … to a
PMHNP for an initial assessment.
True or false: After speaking with the patient, an appropriate screening tool for the
PMHNP
to use would be the Geriatric Depression Scale.
72.
Question:
A middle-aged man who works over 50 hours a week is being for
depression and anger management. He states, “I am even more… when I come
home and my wife wants to argue about stupid stuff. All I want to do is come home,
take a shower, and eat. Is that too much to ask?” The PMHNP explains that people
can be assertive, aggressive, and passive. She encourages the patient to be more
assertive and begins role-play with assertive training. The PMHNP determines that
the patient is beginning to understand when he states:
73.
Question:
At the initial interview with a patient, the PMHNP reviews the
condition of receiving services, including limits that will be imposed on
confidentiality. During the discussion, the patient shares information that the PMHNP
is legally … to report.
True or false: If the PMHNP does not report information that s/he is legally required to
report, state laws govern the consequences which include penalties for not
reporting, especially child and elder abuse.
74.
Question:
The PMHNP is working with a patient who has dissociative disorder
and requests pharmacological interventions for dealing with her trauma. What
education does the PMHNP provide to the patient regarding medication therapy?
75.
Question:
The PMHNP is having a therapy session with Charlotte, a 20-year-old
victim of date rape. The patient states, “I shouldn’t have been there; I should have
just gone home. This was all my fault; how could I have been so stupid?” Using the
Socratic method, what is the PMHNP’s best response?
76.
Question:
The PMHNP is caring for a patient who the PMHNP believes would
benefit from a relational psychodynamic approach to therapy. Which action made by
the PMHNP demonstrates appropriate use and understanding of the relationship
psychodynamic model?
Please help me the answers. Thank you.

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Answer the two following questions:
1. What ethical principles did Eunice Rivers attempt to uphold in her long nursing practice? Explain your answer.
2. Ought she to share part of the blame for the reprehensible research project that involved withholding both accurate information and appropriate treatment? Explain your answer.
Revisiting Nurse Rivers
Lisa Kearns
Keywords: narrative medicine, Tuskegee study, race
INTRODUCTION:
The Tuskegee syphilis study’s most enduring figure is also one of its most intriguing. Nurse Eunice Rivers was instrumental to the study for both procuring its members and then keeping them involved in it. Straddling as she did the professional medical world and the world of the study’s subjects, she was the ideal link between the disparate spheres.1 Over the years, historians who have studied Rivers have found her to be a complex character: a black woman who betrayed her race even as she sought to improve the black subjects’ well-being; a nurse who betrayed her profession by dooming those she was charged with caring for. Through modern eyes, she becomes more victim than betrayer: a victim of her gender, powerless to speak up in a man’s world, or a victim of race herself, powerless in a world controlled by whites.2 Susan Smith, in “Neither Victim Nor Villain,” analyzes the Tuskegee study from the perspective of Rivers as a black professional, in the historical context of her gender and race. 3 Another, equally compelling way to look at Rivers is also within a historical context, again as a medical professional, but this time as one attempting to practice that profession during an economically devastated and racially repressive period of American history. The poverty and unemployment prevalent in the rural South of the 1920s and 1930s is the background against which Rivers ought to be evaluated. And although social conditions don’t provide excuses for her involvement in the infamous study, they do offer a context in which to try to make sense of her participation.
ANALYSIS:
The economic boom before the crash of 1929 didn’t skip the South, but its effects there were much different than in other parts of the country. By 1920, for the first time in United States history, most Americans lived in cities, and by 1940 an additional 6 million farmers had left the fields for urban areas, among them cotton growers from the South.4 For rural America, then, the boom before the bust meant a population drain, and in the decade following World War I the South was the most rural region in the country.5 As wartime demand for agricultural products (chiefly cotton) gave way after Armistice Day to material surpluses and over farmed land, farmers migrated in droves to urban centers. Left behind were those who either could not or would not follow suit. Yet, David Kennedy notes, “the urbanization of early twentieth-century America can be exaggerated. More than one in five working Americans still toiled on the land in the 1920s.” At the same time, “a stubborn agricultural depression, the product of war and technological change, badly exacerbated the problems of the countryside.” In 1930 four-fifths of all blacks remained in the South.6 President Herbert Hoover decided to address the social problems of the time by gathering the brightest minds in the country (a month before the market crash of October 29, 1929) and asking them to amass nationwide data and analysis that would be, according to Hoover, “the basis for the formulation of large national policies looking to the next phase in the nation’s development.”7 The report was delivered in 1933: the exhaustive Recent Social Trends, which provided data on everything from the nation’s mineral resources to the impact of new technology on work and home life. Writes Kennedy, “From its turgid prose and endless tables emerged a vivid portrait of a people in the throes of sweeping social, economic, and political change, even before they were engulfed by the still more wrenching changes of the Depression era.”8 That turgid prose also revealed a stark conclusion: If residents of the rural South were suffering during that era, black residents were suffering significantly worse. Earlier immigration restrictions (via literacy tests, for example) culminated in a 1921 quota law, followed by an even more stringent one in 1924 and then another in 1929. 9 The resulting reduced immigrant workforce created employment opportunities for blacks in towns and cities, furthering emptying rural farms of tenant farmers and sharecroppers; a devastating boll weevil infestation in Southeast cotton fields spurred even more relocation as crops failed.10 Those who stayed in the countryside lived in deplorable conditions. By as late as 1940, homes for both black and white tenant farmers were valued at around $250. Few houses had running water; fewer still had flush toilets.11 Black farmers also faced a credit system that was particularly unfavorable to them. The usurious interest rates they were charged (15 percent to 35 percent) drastically ate into already meager profits. “This crop mortgage system is weak to begin with and its abuses make it even more burdensome,” Recent Social Trends reported. “With these handicaps the returns from farming are small… After this small product has been divided between tenant, the landlord and the furnisher of credit, the shares are inadequate to support a good standard of living.”12 It was in this bleak social and economic landscape that Rivers found herself when she was starting her career. And if she hadn’t noticed it from the confines of the nursing program at the Tuskegee Institute, she witnessed it firsthand after her 1922 graduation in her first job, with the Movable School. Tuskegee Institute founder Booker T. Washington wanted to teach agricultural techniques to black farmers in the last decade of the 19th century. That idea led to the establishment of an agricultural extension department at Tuskegee and ultimately the Movable School,13 so named because it brought a learning center to people (first by a mule-drawn wagon and later via truck). The original “Farmers’ College on Wheels” initially educated farmers on new technology and methods to help improve crop and livestock yields. In 1918, federal funding allowed the hiring of home economics instructors, who taught women canning, cooking, and cleaning,14 and later public health professionals came on board to teach basic hygiene and sanitation skills.15 In 1923, Rivers joined the school as a public health nurse. In addition to basic hygiene, she taught women and midwives safe birthing methods, childcare, and how to tend to the sick, and provided men information on “social hygiene,” euphemism for sexually transmitted diseases.16 The Movable School ventured to the farthest rural corners of Alabama, including Macon County, the pool from which prospective subjects for the Tuskegee study would be drawn. For Rivers, the Movable School was more than just an opportunity to advance the Tuskegee Institute’s philosophy of service to the indigent; it was a job at a time when jobs were scarce, and it was a good one at that. Landing it was an achievement in itself. Black nurses had fewer employment opportunities than white nurses did, and Southern black nurses lucky enough to find work were paid lower salaries for performing the same duties as their white counterparts. In Alabama, for example, white nurses were paid $110 a month by the board of health, while black nurses received $65.17 The openly racist attitudes of even those in the profession compounded the economic inequalities. Darlene Clark Hine writes of Margaret Bruesche, a white nursing teacher in Fairfield, Alabama, who felt that “the negro woman has no place as a graduate nurse.” They weren’t smart or well educated, “they are not conscientious, and their sense of responsibility is very weak.” (At least Bruesche was ostensibly assessing professional skills. A white nursing superintendent at Atlanta’s Grady Hospital at the time felt black nurses hadn’t “any morals… They are such liars…and will cut up each other’s clothes for spite.”)18 Rivers remained with the Movable School for nine years, until the Depression forced financial cutbacks that led to the elimination of her position, leaving her to choose between unemployment and a night nursing supervisor position at the John A. Andrew Memorial Hospital at the Tuskegee Institute. She chose the latter. She hated working the night shift, and less than a year later, as she was preparing to migrate north herself, she heard about a job with the United States Public Health Service, working on a study of the effects of untreated syphilis on black men.19 It was an assistant’s position, paying a then- attractive $1,800 a year.20 River’s years with the Movable School in and around Macon County, and her concurrent work for the Bureau of Vital Statistics for the Alabama Health Department compiling birth and death records in the same area, were on-the-job preparation for the Tuskegee position. Her experience and performance were impressive enough that Dr. Eugene Dibble, medical director of the Tuskegee Institute and head of the Andrew Hospital, recommended Rivers, who had been one of the institute’s star nursing school pupils, for the opening. She was hired for the study in 1932 to monitor the participation of its black subjects.21 With 21st-century eyes it might be difficult to see how a black woman would be willing to participate in something called “The Tuskegee Study of Untreated Syphilis in the Negro Male.” But in light of the prevailing economic conditions in the rural South early in the previous century, it is not so hard to discern reasons why. Syphilis was rampant and posed a serious health threat, and treatments available then were harsh. (“I saw so many reactions with these medications,” Rivers said in an interview). 22 The natural progression of the disease was to be studied in hopes of determining better treatments.23 By taking the job with the U.S. Public Health Service, Rivers would be working to help the people she knew to be in desperate need of medical attention. Also, in the beginning decades of the 1900s, it was presumed that the course of the disease progressed differently through blacks than it did through whites—the Tuskegee study would complement the Oslo study of untreated syphilis in whites.24 “This is the way I saw it: that they were studying the Negro just like they were studying the white man, see, making a comparison,” Rivers said later.25 Yet given the scarcity of good jobs for black women, in the rural South in particular, a perhaps more compelling reason for Rivers to join the study is simply that it offered employment—and a chance to get off the odious night shift. (“I was so glad to go off night duty that I would have done anything,” Rivers said). 26 That the position was one in the career for which Rivers had trained was a bonus. Nursing positions were not easy to come by, and the Depression was forcing state public health departments to cut funds.27 The unemployment rate for the country was approaching 25 percent.28 Rivers was an ideal candidate for the job. She had been an exemplary student at Tuskegee. She’d done administrative work for the Bureau of Vital Statistics, and nursing school had trained her to examine patients. The Movable School had taught her public outreach and the interpersonal skills of a public health nurse; her personality and tact were remarkable.29 In fact, Dr. Dibble cited her effectiveness as a public health worker when he suggested her for the Tuskegee position.30 The relationships she established with the people in Macon County from her Movable School days would be the key to her success in the Tuskegee job. Other syphilis studies were being conducted at the time, and a lack of patient compliance with treatment protocols was an ongoing, pervasive challenge. A Birmingham, Alabama, doctor who had worked with public health syphilis programs noted that failing to keep up with treatment until cure was an issue for both blacks and whites, and that developing a way to keep patients compliant would be essential to any program’s success.31 As it turned out, Rivers excelled at making sure that patients enrolled in the study stuck with it. The study was originally designed to last six to eight months, but of course it went on far longer, and by the time the decision was made to leave the termination date open-ended, Rivers was a firmly entrenched Tuskegee team member. After all, notes Susan Smith, “Rivers considered her participation in the study merely a continuation of her previous public health work.”32 Over the course of the study she had become more than just an assistant; she was, if not in title, the de facto chief liaison between the doctors and the subjects. Dr. Raymond Vonderlehr, director of the Public Health Service’s venereal disease division and the head of the study from its inception till 1943, acknowledged River’s skills in ensuring the ongoing compliance of the subjects.33 If River’s complicity in withholding treatment in the original study can be understood within the economic and employment contexts of the time, can it also explain why a caring, dedicated nurse would continue to risk the lives of her patients—patients she had known and followed for 15 years—after an accepted treatment for syphilis became available, in the mid-1940s? Yes, but this time Rivers needn’t be regarded as someone lucky enough to have a job but rather as a dedicated Tuskegee team member. If she was an entrenched member of the Tuskegee team when the decision was made to continue the study indefinitely, by the time penicillin was widely available she would have been a full-fledged “company woman.” Others in the study came and went over the years, but Rivers steadfastly remained. (She was replaced by Elizabeth Kennebrew in 1965 but continued to help Public Health Service physicians when they were in town and remained in contact with the men). 34 Rivers was a loyal employee who identified more with the researchers—the company—than she did with the subjects. Born and raised in rural Georgia,35 she may have come from the subjects’ world, but even at the beginning of the study she didn’t live in it anymore. Ten years out of nursing school, she was working steadily, both for Tuskegee and in her midwife-training capacity.36 She was a working professional. Smith refers to “Rivers and other black professionals,” and suggests that this professionalism may have “blinded them to the high price paid by poor, rural black men in the study.”37 To the scientific assistant part of Rivers, the poor, rural black men were subjects; to the nurse part of her they were patients. But more important, they were her job. She was working for an organization whose purpose was to gather data on untreated syphilis in black men; thus, it would have been more surprising if treatment had been provided. As some journalists realized at the time, given the study’s design, withholding penicillin was a foregone conclusion. Penicillin was withheld because all treatment was withheld.38 Darlene Clark Hine suggests that “[years] of conditioning and living in the South made it virtually impossible for Rivers to have rebelled against a white, male government doctor, the ultimate authority figure in her world.”39 Looking at Rivers as a loyal employee accounts for her subservience to the white government-official doctors in charge in a different way: They were her bosses, and as a good employee she did what the bosses told her to do. Telling moments from two interviews with Rivers suggest she strongly identified with the Tuskegee study team. She rarely spoke of her role in the scandal,40 and so publicly expressed few regrets. However, in a 1977 conversation with Helen Dibble and Daniel Williams, she allowed one: that the results of the study’s labor may have been lost. “[T]his was the thing that was so disturbing to me was that somehow all of the records of this study and the health department have been destroyed,” she told them.41 Another moment came in an interview with James Jones several years after a $10 million class-action lawsuit against the U.S. government was settled with the living participants of the study, in 1974.42 Jones and Rivers were driving through Macon County when Rivers saw a former study participant in a field and went out to say hello. When the man asked her why she had stopped coming by to see him, she told him, “You don’t get the money and Nurse Rivers too.”43
CONCLUSION:
Considering Rivers in the specific socioeconomic context in which she lived is one more way to make sense of her ongoing participation in what is now known as a deadly racist medical experiment perpetrated against Rivers’s own friends and patients. By first seeing her as fortunate to have secured a position with the study and then as a loyal team member later on, she escapes the harsher accusations of race traitor and coward; more important, it is consistent with her remaining in history the dedicated, caring nurse she professed to be. “Really and truly,” said Nurse Rivers, “when we were working with those people…that was the joy of my life.”44 Today she might simply be called a cog in the machine, but half a century ago she was someone lucky to be working in her chosen profession when nearly a quarter of the country was not working at all, someone who did not have the luxury of resigning in protest.
1 James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment—A Tragedy of Race and Medicine (New York: The Free Press,
1981), p. 6 2 Susan M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: The University of North Carolina
Press, 2009), p. 168 3 Susan L. Smith, “Neither Victim Nor Villain: Eunice Rivers and Public Health Work,” Tuskegee’s Truths, ed. Susan M. Reverby
(Chapel Hill: The University of North Carolina Press), p. 349 4 David M. Kennedy, Freedom from Fear: Part I: The American People in the Great Depression (New York: Oxford University Press,
1999), p. 16 5 Ibid., p. 18 6 Ibid., p. 16-17 7 Ibid., p. 11-12
8 Ibid., p. 12 9 Recent Social Trends in the United States: Report of the President’s Research Committee on Social Trends (New York: McGraw-
Hill Book Company, Inc., 1933), p. 557 10 Ibid., p. 566 11 Wayne Flynt, “Poverty in Alabama” (Encyclopedia of Alabama, http:encyclopediaoflabama.org, November 2007) 12 Recent Social Trends, p. 570 13 Felix James, “The Tuskegee Institute Movable School, 1906-1923,” Agricultural History, July 1971: Vol.45, No. 3, p. 202 14Ibid., p. 206 15 Ibid., p. 208 16 Reverby, Examining Tuskegee, p. 170 17 Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession 1890-1950 (Bloomington:
Indiana University Press, 1989), p. 92 18 Ibid., p. 101 19 Reverby, Examining Tuskegee, p. 170 20 Jones, Bad Blood, p. 102 21 Ibid., p. 6 22 Laurie interview; Eunice Rivers, Stanley H. Schuman, Lloyd Simpson, and Sidney Olansky, “The Twenty Years of Follow-up
Experience in a Long-Range Medical Study, Public Health Reports 68 (1953): 394, cited in Jones, Bad Blood, p. 163 23 “The U.S. Public Health Service Syphilis Study at Tuskegee” (Centers for Disease Control and Prevention,
www.cdc.gov/tuskegee) 24 Smith, “Neither Victim Nor Villain,” p. 354 25 Laurie interview, p. 167 26 Ibid., p. 11 27 Ibid 28 Robert VanGiezen, Albert E. Schwenk, “Compensation from Before World War I Through the Great Depression,” Compensation
and Working Conditions, Fall 2001 (Bureau of Labor Statistics, www.bls.gov/opub/cwc/cm20030124ar03p1.htm, posted Jan. 30,
2003) 29 Clark Hine, Black Women in White, p. 155 30 Jones, Bad Blood, p. 111 31 Ibid., p. 46 32 Smith, “Neither Victim Nor Villain,” p. 358 33 Jones, Bad Blood, p. 116 34 Reverby, Examining Tuskegee, p. 172 35 Ibid., p. 169 36 Ibid., p. 172 37 Smith, “Neither Victim Nor Villain,” p. 360 38 Jones, Bad Blood, p. 9 39 Clark Hine, Black Women in White, p. 156 40 Reverby, Examining Tuskegee, p. 168 41 Helen Dibble, Daniel Williams, “An Interview with Nurse Rivers,” Tuskegee’s Truths, ed. Reverby, p. 327 42 The U.S. Public Health Service Syphilis Study at Tuskegee: The Tuskegee Timeline” (Centers for Disease Control and
Prevention, www.cdc.gov/tuskegee) 43 James H. Jones to Susan M. Reverby, Personal Communication, July 7, 2004, cited in Reverby, Examining Tuskegee, p. 183 44 Jones, Bad Blood, p. 161

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1. What struck you most about the role Ellen plays as a care coordinator?
2. In your clinical experience thus far, can you describe a complex medical patient you have cared for that would have benefited from services similar to those Ellen has described? Explain why.
Lingos welcome to the Cure Coordination meet the professional podcast today. I’m really pleased to have. Ellen is our guest. She’s going to talk to us about her role as a cure for denator. Can you tell us? About your program and the types of patients you see. Sure. I’m the nurse practitioner for the Children’s Complex Care program, which is a small program that was started about six years ago to provide intensive medical care coordination for children who have multiple medical needs are hospital. Has a very high level of acuity as a teaching hospital, we see the sickest kids not only in the area but even some children who come from far away to be at our hospital. Some of those children have very specific diagnosis. Their children with a specific cardiac disease or children with a specific type of cancer, or perhaps children who need an organ transplant for each of those conditions. For each of those services, there’s a team that addresses. The comprehensive needs that that child met family has. However, there are many children who are cared for at hospitals like ours who have multiple concurrent medical problems. These might be children who were born very prematurely or might be children with genetic syndromes. These are children who have medical problems that have that affect multiple body systems. So for instance, we may have a child with a genetic syndrome who has cardiac disease and respiratory difficulty and has an immune deficiency and may also have difficulty eating the kids. We take care of require a lot of behind the scenes work and. That’s the reason that our program came about in recognition of the fact that there are a lot of just as well. There’s a lot of stuff on a lot of different levels that need to be done for children who have high levels of medical complexity, we do things on a lot of different levels to help the entire team. And when I say the team, I mean. The medical providers, the nursing providers, providers who care for the child in the community at home and in the school setting, and also the children and the family themselves. As part of that medical team. So we try to bring everybody together to help the the child in the family. Identify what their goals are and help meet those goals. What a great service can you give us? A couple of examples of the types of patients you care for and the role you play in their care. Oh gosh, we had a little fellow who came out of the hospital who had been here for many many months. Hadn’t really been home, had been back and forth between the hospital and a rehab facility, and he had, like, I don’t know, seven or eight appointments in the first three weeks. Here’s this mom trying to figure out. How to take care of a child who was very fragile and also add a lot of technology. A lot of our kids have feeding tubes and a good number of them rely on help breathing, which may be oxygen or what we call non invasive ventilation which is CPAP or BIPAP or even a tracheostomy and ventilator. And we have some kids with central lines which are semi permanent Ivs, so that’s a lot. And then there’s a matter of getting a kid getting any kid but getting a kid with all that equipment to the hospital. And just as this parent was trying to get her footing at home, we’re saying, OK, you have to come back two times next week and three times the week after that. Twice the week after that, and so one of the things that I can do is sit down and say, OK, this is really important now. This can wait a couple of weeks or this. I’m not sure if we can stall, but I have a Direct Line to this medical provider, so let me give him or her a call and or send a message to find out if we can delay. Or maybe it’s possible for you to see Gastro Enterology and from analogy on the same day. So that’s only one trip to the hospital. I work with a Community health worker who works very closely with the parents on helping them schedule appointments, but also helping them learn to schedule their own appointments, helping them with transportation which sometimes needs to be in an ambulatory, even an ambulance. And helping them set that up and also helping them learn to set that up so some of the things that we do are very nuts and bolts. Things help identify which appointments are most important, help the kids get here, help coordinate the Mondays and times that are actually feasible. I also do something that I fall hurting the cats. Which is bringing the different matter members of the medical team together. I just saw a little boy today. He’s not a little boy anymore. He’s a big boy. He’s 12 now, but I was remembering talking to his dad about one of his hospitalizations when the program was new and he was new to the program. He has pretty severe neurological impairment and was coming in for frequent pneumonias, so he would come into the hospital and they would treat the pneumonia and he would be here for a couple of weeks and he would get better and then it would happen again. So what we were able to do in the complex care program was bring a group of his medical providers together. To see what can we do to interrupt this cycle and we did a bunch of different things. We adjusted his epilepsy medicines because when he’s on too much medicine, he’s sleepy, which makes him more likely to aspirate when he’s done not enough medication, he’s more likely to seize, which makes him more likely to aspirate. So we did that. We also converted his feeding tube from a G tube feeding tube that goes directly to his stomach to a different kind of tube called the GJ tube that extends down into his intestine so that the feeding is going in. His formula is going in further down. Into his body and he is less likely to reflux contents up from his stomach and have that landed his lungs and cause pneumonia. And we also involve physical medicine and rehabilitation and arranged for him to get. Botox, like Botox like Botox, which we use in clinical settings as well to decrease his saliva production? Doing that combination of things was really successful in decreasing his hospitalization. It’s not eliminating them because he’s. A fragile kid and he’s gonna get sick. But we were able to bring the team together and discuss a a multifaceted approach to getting him more stable. Your patients are so complicated. I can see why care coordination is such an important part of their care, and I’m particularly struck by your advocacy for your patients and families and the way you work to collaborate with a diverse medical community that’s required to care for your patients. I can see that it has such a positive impact on everyone involved. It sounds like a lot of work, so I need to ask what is your typical caseload like? We have 53 kids on our caseload. There are some who I talked to their parents three times a week and there are some who honestly I haven’t talked to for three or four months. We find that when children come into the program, there’s a trajectory. There’s like a hump to get over and that make take. One or two months and that may take four or five months, but we find that with time we can identify what the big issues are for the child and family we can get to know the medical team and we can put some plans into place. Sometimes we find parents just don’t know who to call. If your kid has cardiac disease and respiratory disease and a feeding tube and they’re coughing and throwing up sometimes the parents really don’t know if they should be calling the cardiologist or the pulmonologist, or the gastroenterologist, or if they should be calling their primary care provider. So we help them figure that stuff. Out so we find that over a number of months that was a lot of handholding from our Community, health worker, and a lot of like I said, hurting the cats between me and the medical providers. We can get the kids and the families to a place of greater stability. We generally don’t make them better. These are kids with serious and life span limiting conditions and sometimes we can improve their health status with the goal of having them live for longer, but often what we’re doing is trying to make their lives and their parents lives easier. And more stable, reduce unplanned hospital admissions, for instance, which are extremely extremely stressful and disruptive. Some of our kids we can really get to a point of stability. We’ve had a couple who really kind of did get better. The nature of their condition was that that they they got better and didn’t need us. We have some who. Things are more under control there. Their parents have it down there. Providers have it down, so they need us much less, but we’ll still say stop by and see them when they’re in the hospital or do a periodic review of their appointments and make sure they’re up to date on everything. And then we unfortunately have some kids. Just condition is declining because they do have degenerative. Conditions and we have some kids who were just. Always gonna be very present on our radar because of the nature of what they have. It sounds like even though your caseload is high as well as their, your patient acuity that some of your patients and their families become increasingly capable of managing for the most part independently overtime, which is of course. The goal of many care coordination programs. What are the parts of your job that you like best? I am in the really lucky position of getting to spend time with my patients and families and knowing them overtime and the opportunity to follow children overtime and see them grow into that lab. And as important to me to see their families grow into velop. We see incredible beauty, we see. Parents who celebrate. These milestones in their children that another parent would have missed entirely, who just loved their children, exactly how they are. I’ve just seen the great pain and great beauty coexist. I think people kind of think that good things and bad things are on a scale, and they pull out. You know they. They they. They equalize, and that’s not what happens. It’s not like a a good thing makes up for a bad thing or a bad thing cancels out a good thing, but I do see how parents live with great pain and children, parents and children live with great pain, but also great talents and great beauty, and that’s great. So as a palliative care provider, I completely agree. What parts of your job do you find challenging? Our medical system is very, very good at high tech stuff. It’s likes to fix things. It likes high tech solutions for fixing things. It has infrastructure for high tech solutions to things it doesn’t have infrastructure for care. The emotional toll and the physical toll on families is unfathomable. The other thing is that, like I feel like the hospital system where you know you’re admitted to like a generalist service and then you get various consults coming in. That’s a system that was developed, you know. However, many years ago it was developed decades and decades ago, and it worked. If you had to keep a patient who came in for something and you just needed to call a cardiology konsult and it was the the one hospital provider attending was overseeing the case and consulting with one specialist. But when you have a kid. In the hospital and four different services have been called to consult, and they’re all going in and out of the room. We’re communicating by text message or relying on people to read our notes in the chart. I liken it to, you know, a family built a house and it’s like a nice little house and they raise their children there and then the. I’ll just Child gets married and they build an addition onto the house. Then the next child gets married and you know, in some cultures there’s like these. These family houses, grown and grown and grown over the years, and it’s wonderful ’cause the whole families living together. But if you were going to build a house for that many people, you wouldn’t have built it the way that we have built our system. And so it’s in the same way that it’s great to have the whole family together. It’s great to have the expertise of so many different people, but how do you pull that together in a coherent system? I work on bridging that gap, but sometimes I feel like the whole system needs to be blown up and and recreated from scratch. What a great analogy. That’s my analogy for the week. OK, So what do you see as the most important skills for someone that does your job? I think you gotta be organized and which I I laugh when I say that because because people who know me and my personal life don’t think of me as the most organized person. But I think that. Organization might not be an innate talent it it originate quality, but it’s something that you can systems in place for. So we’ve been thinking a lot about that. We have a little spreadsheet for each kid where it has the kids name, and then it has all the different specialties the kids have ever seen. In their last appointment in their next appointment that can sink into a calendar week, we set it up on Excel. I didn’t set it up. Somebody set it up on Excel so that you can sync so I can know all the kids who are coming in on a given day, and so I can. Also every time I go to talk to that parent by. Check you know, I I I have like a reference point so I just wanna ask real quick so does that mean then you see patients primarily in the hospital setting and then your community health worker sees patients in their homes? We actually don’t do home visits. I would love if we had have the bandwidth we don’t have clinic time. We kind of follow our kids where they are so we do a lot of work by phone and some of that’s reactive, meaning that the parents call and they have a specific question and we answer that specific question and if it’s not a crisis we also try to stay. And while we have you. And checking on other thing, this was the medication picked up gicu haven’t been too. This specialist in a little while, is there a reason for that and some of that is proactive where we’re you know, well, we’ll call families on a on a regular schedule and we’ll check to make sure they have all their medications, all their supplies. If they get home, nursing or home. Other sorts of Home Care Services. Stats in place. Well, when they’re admitted to the hospital will stop up and see them. Sometimes I’ll round with the teens. Sometimes I’ll arrange a either team meeting just with the medical team or a family meeting with medical team and the family. And sometimes it’s just kind of pie. You know, we’ll just go in to say hello and and there isn’t a particular issue. That the medical team needs us for, but we just, you know, check in with our families to maintain that relationship. And similarly when they come in for outpatient appointments because we have that set up with the cell spreadsheet. I all know who’s coming in on every any given day, and I can wander by and see them. And sometimes one of the somebody in cardiology. That said I was coming by to see a patient, they said. Is there problem? And I said no, I’m just saying hello. She said you’re doing howdy rounds and I love that yeah I was just going to say hi and that’s just a good way of us building trust in continuity with the families. Sometimes I’ll touch bases with the family just to make sure they’re up to date on their appointments and their nursing and their meds. And I’ll do that in. Person while they’re here, sometimes I’ll address another issue I mentioned that I worked in GI and so if so I know that. So if the kids having like a problem with their GPU, Venice coming into neurology, sometimes I’ll stop up to look at that. But another thing that I sometimes do is I’ll go to appointments either because. I think the parent doesn’t really understand why they’re being sent to the specialist or they have a complicated medical history and I wanna. Be able to give the specialists in background or because I think that the parent doesn’t really understand why they’re going to the visit. You know, I’m at the point where I know most of the clinicians here, and I know this person might not be the most clear explainer, and so I can go and be a second set of ears or. You know, sometimes the parent knows exactly why they’re there. I have a mother who hates to go to the neurologist because her child has a static condition. She’s not getting better and it always feels like bad news. And so if I’m able, if I’m free, I’ll just go because you know, we’ve known each other for a long time and it’s hard for her to be there. You have a great job. So how do you see the future of programs like yours as a field? I don’t have any insight into where the field is developing, but. It’s very clear to me that as. Medical technology advances and as medical care gets more and more complicated and there are more and more players than care, coordination is going to be. More important than ever, because it’s just too complicated. It’s just too complicated. There’s too many moving parts to keep track of. There is, in my opinion, too much attention to the high tech and the breakthrough and the keeping people alive. For longer and have that be the default, more end better and families are struggling in social situations. The most common question I get asked is oh, is there something like that for older people? That’s just what I need for my mother. That’s just what I need. For my father. And of course you know the answer to that question is yes, there are all kinds of care coordination programs for older adults. So I think on that note we’ll wrap up. Thanks again for taking the time to talk about the very important work that you do for these children and their families and bringing the role of care coordinator to life for the students. That’s the end of this podcast. Please complete the discussion board below.

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MULTI 3 EXAM 1
A 40-year-old woman has high vaginal bleeding. Which question is the priority in evaluating the client’s chief complaints?
“Is the bleeding related to the menstrual cycle or intercourse”
“Are you having any sensations of pain or cramps”
“Are you sexually active and do you use oral contraceptives?”
“Are you feeling weak, dizzy or lightheaded?”
A nurse is caring for a 50-year-old male patient presently diagnosed with erectile dysfunction (ED). Which of the following is a possible cause of ED?
Hypertension week 2
Sexually transmitted diseases
Opioid overuse
Caffeine consumption
Which of the following interventions would meet the multidimensional needs of a 45-year-old male who was recently diagnosed with testicular cancer (Select all that apply)?
Consult the dietician for cultural dietary needs
Conduct a cultural assessment
Provide a psychosocial assessment
Provide emotional and spiritual support
Offer client family-centered care
A nurse is providing education at a health fair regarding breast cancer. Which of the following informational brochures would be more beneficial to distribute to the participants?
Self-breast examination
Diet modification
Stress reductions
Exercise regimen
The nurse knows to include which of the following when teaching a client about the common cause of pyelonephritis?
Urinary retention and ascending infection of the urinary tract
Delayed voiding
Renal calculi
Previous UTI
A nurse is caring for a 32-year-old female with a history of breast cancer. Which of the following should be included in the client education?
Annual mammography
Clinical breast examination every 2 years
Herbal supplements
Preventive screening to begin at the age of 45
A client is emotionally upset after the diagnosis of endometrial cancer. What action by the nurse is best?
Leave the client alone for an extended period for reflection time
Create an atmosphere that supports acceptance and discussion
Tell the client that her emotional response is unacceptable
Limit visits from family and friends
A nurse is providing education to a female client regarding cystitis. Which of the following should the nurse include in the client education?
Avoid the use of feminine sprays
Increase frequency of douching
Utilize a diaphragm for birth control
Wipe perineum from back to front
The nurse is teaching a group of women about the prevention of toxic shock syndrome. What preventive measure does the nurse include in the teaching? (Select all that apply)
‘Avoid the use of high absorbency tampons”
“Use sanitary napkins at night”
“Avoid using internal contraceptives”
“Have your partner avoid using condoms”
“Change tampons every 8 hours”
A nurse is caring for a 58-year-old male who recently underwent an open radical prostatectomy. Which of the following nursing interventions would be appropriate for the client? (Select all that apply)
Pain management
Venous thromboembolism prevention 1484
Monitor intake and output
Maintain bedrest
Monitor for signs of infection
Based on American Cancer Society recommendations, what does the nurse teach the patient about screening for prostate cancer?
Beginning at age 30, all men should have an annual digital rectal examination
Men that have a prostate specific antigen (PSA) test done do not require a digital rectal examination
Men with multiple first-degree young relatives with prostate cancer at an early age should discuss screening with their healthcare providers at age 40
Asian-American men should start screening at age 55years
Which of the following should the nurse include in the education fir a client who recently underwent cervical ablation for cervical cancer?
Resume tampons in 24hours
Do not douche
Tub baths are preferred over showers
Resume sexual intercourse in one week
A nurse is caring for a 56-year-old male patient who was recently diagnosed with benign prostatic hyperplasia. Which of the following is a common assessment finding related to this disorder?
Painful urination
Penile discharge
Difficulty starting urine stream
Increased daytime urination
The client is being treated for both BPH and hypertension. Which alpha-blocker does the nurse anticipates will be prescribed for the client?
Doxazocin alpha-blockers
Finasteride 5-alpha reductase inhibitors
Dutasteride 5-alpa reductase inhibitors
Sildenafil phosphodiesterase (PDE) inhibitors
A nurse is caring for a 30-year-old female client that has been diagnosed with uterine leiomyoma. What the nurse expects to see as the client’s presenting chief complaints?
Feeling of vaginal pressure
Heavy vaginal bleeding
Intermittent pain
Urinary changes
Which of the following is considered a risk factor for the development of breast cancer?
Age
Race
Activity
Genetics
The nurse knows that which of the following is considered a late sign of prostate cancer?
Difficulty starting urination
Hematuria
Frequent bladder infections
Urinary retention
A client experiencing secondary syphilis may experience all of the following signs and symptoms except? Antibiotics
Fever
Headache
Muscle aches
Diarrhea
A nurse is caring for a client who was recently diagnosed with acute kidney injury. Which of the following are possible causes of acute kidney injury due to perfusion issues?
Bladder cancer
Myocardial infarction
Kidney stones
Lupus
A nurse is caring for a client who was recently diagnosed with chronic renal failure. Which of the following is a treatment option for a client with renal failure?
Fluid resuscitation
Diuretics
Dialysis
Diet rich in potassium and magnesium
You are providing discharge instructions to a client who is prescribed antibiotics for the treatment of sexually transmitted disease. Which of the following should you include in the medication administration?
Refrain from sex for at least 7days 2
Take antacids prior to taking the antibiotics
Take medication prior to bed
Take medication with a high-fat meal
Which of the following are treatment options for a client with renal cell carcinoma who only has one kidney and is not a candidate for surgery?
Microwave ablation
Chemotherapy
Nephrectomy
Radiation
The nurse knows to include which of the following when teaching a client about the most common cause of acute pyelonephritis?
Urinary retention and ascending infection of the urinary tract
Delayed voiding
Renal calculi
previous UTI
Decline as a new diagnosis of testicular cancer the nurse recognise which of the following is the sign of testicular cancer
painful enlargement of the testicle
painless enlargement of the testicle
painless shrinking of the testicle
painful shrinking of the testicle
Dino’s is providing information to the client who has genital apes. What priority assessment would be the nurse so concern
after a diagnosis of hsv minus 2, there are likely to be true to theory outbreak during the
transmission of genital apes can occur from a partner who does not have a
a apps simplex virus minus one hsv minus one genita infection can occur with aura genitor Contacts
janitor apes simply virus minus two is more common in women than in men
During a routine prenatal examination, a pregnant woman’s urine is found to contain glucose. What does this finding indicate to the nurse?
The patient should have further testing for gestational diabetes.
The patient should have a lover enzyme panel completed
The patient is eating excessive calories
It is because of a decrease in GFR
The nurse is caring for a male who was recently diagnosed with benign prostatic hypertrophy. Which of the following medications should the nurse instruct the client to avoid?
Calcium channel blockers
Anticholinergic
Beta-blockers
Nonsteroidal anti-inflammatory drugs
A 58-year-old female presents to the Dr’s office for a checkup. She communicated that she has not previously had any preventive screening. Which of the following would increase her risk of preventing breast cancer?
Having her first child at age 25
Dense breasts
Low socioeconomic status
Stress
Which of the following clients are at risk of developing genital warts?
Those who have unprotected sex
Drug abusers
Individuals with opioid addictions
Males/females in many relationships
Jane is a 28-year-old female who presented to the emergency room with genital warts lesion. She was diagnosed with genital herpes. Which of the following nursing interventions would be applicable to this diagnosis?
NSAIDS
Limit urinary frequency
Application of heat
Douche administration
The obese 54-year-old client describes excessive menstrual bleeding that occurs approximately every 10 days. The nurse prepares the client for which diagnostic test that is used to evaluate for endometrial cancer?
Bimanual pelvic examination
Transvaginal ultrasound
Sonohysterography
Endometrial biopsy
A nurse is caring for a client with polycystic kidney disease. The nurse anticipates all of the following interventions or treatment options except which of the following?
Pain management
Blood transfusion
Blood pressure control
Genetic counseling
A nurse is caring for a 30-year-old male client recently diagnosed with testicular cancer. Which of the following nursing intervention should be included as a priority for the client?
Education on options for sperm banking
Education of likelihood of testicular removal
Nutritional assessment
Spiritual assessment
A client with uterine leiomyoma reports a feeling of pelvic pressure, constipation, urinary frequency and says, “I can’t button my pants anymore”. What does the nurse assess further to evaluate specific to the client’s complaint?
Fluid imbalance
Abdominal distension or enlargement
Bowel or bladder incontinence
Vagina bleeding or discharge
the nurse has viewed the lab result of the client being treated for nephrotic syndrome. And has noted a normal glomerular filtration rate (GFR). Which of the following dietary interventions does the nurse educates the client to incorporate into their diet?
Increase the intake of vitamin K to decrease the risk of thrombus
Decrease fluid intake because the kidneys are retaining an excessive amount of fluid
Increase sodium intake to help prevent hypotension secondary to fluid loss
Ensure adequate protein intake in the diet
Which of the following are common assessment findings for a client with pyelonephritis? (Select all that apply)
Inability to void
Abdominal distension
Foul-smelling urine
Nocturia
Flank pain
Linda is a 45-year-old female that reported to the doctor’s office with the concern regarding finding a lump during her monthly self-breast examination. She denies having a family history of breast cancer. During her physical examination, the provider notes no visual abnormalities of the breast, normal nipples, no nipples and no discharge. The nurse anticipates the provider will order what test?
Mammogram
Genetic testing for breast cancer
Ultrasound
Biopsy
A nurse is caring for a client who is status post-nephrectomy secondary to renal cell carcinoma. Which of the following nursing interventions is the highest priority in the postoperative management of the client?
Monitoring for hemorrhage
Pain management
Coughing and deep breathing
Early ambulation
A nurse is caring for a client who has recently been diagnosed with erectile dysfunction. Which of the following are treatment options for this disorder?
Phosphodiesterase-5 (PDE-5) inhibitor
Exercise
Blood pressure control
Penile transplant
A nurse is caring for a client who has a diagnosis of urolithiasis. Which of the following findings should the nurse expect in this male client? (select all that apply)
Flank pain
Bradycardia
Pain radiating to the shoulder
Nausea and vomiting
Testicular or scrotal pain
A nurse is caring for a client who presented to the emergency room with the complaints of fatigue, hematuria, and weight loss. Upon physical examination, the client’s blood pressure is 190/100mmHg with positive jugular vein distension and lower extremity edema are present. A urinalysis revealed the presence of red blood cells and protein, serum, BUN and creatinine are elevated. Based on these findings, the provider suspects the client has acute glomerulonephritis. Which of the following test would the nurse expects the provider to order?
CT scan of the abdomen and pelvis
24-hour urine collection
AST & ALT
Serum potassium
During the first 24hours after transurethral resection of the prostate (TURP), what is the priority assessment concern in the nursing care plan?
Hemorrhage
Infection
Hydronephrosis
Confusion
A nurse is teaching an older client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
“Have an eye examination once per year”
“Examine your feet carefully everyday”
“wear compression stockings daily”
“Maintain stable blood glucose levels”
The nurse educates a teenager on the benefits of receiving the human papillomavirus (HPV) vaccine as protection against which type of cancer?
Endometrial cancer
Cervical cancer
Ovarian cancer
Uterine cancer
What does the nurse include in the discharge teaching for a woman who had a total abdominal hysterectomy for endometrial cancer?
Do not lift anything heavier than 20lb/ less than 15
Sexual activity may be resumed in 2 to 3 weeks
Gradually increase walking as exercise but stop before becoming fatigued 1463
Wait for 24hours after discharge to begin driving
A nurse is providing education to a client diagnosed with urinary incontinence. Which of the following should be included in the client education?
Avoid fluids and drinks that contain caffeine
Increase fluid intake
Increase cranberry juice consumption
Avoid salt intake
Sue, a 32-year-old female presents to the physician’s office with complaint of heavy menstrual bleeding and prolonged periods. She states that this has been going on for approximately six months. She avoided coming to the Doctor’s office because of fear of possible cancer. Which of the following will be performed based on patient’s symptoms?
Liver function test
Pelvic testing
Fecal occult blood test
Genetic examination
The nurse includes which of the following in self-management teaching for a client diagnosed with vulvovaginitis?
Wear cotton underwear 1471
Wear tight-fitting clothing for support
Use feminine sprays
Wipe from front to back only after bowel movements
A client with urinary tract infection has just been diagnosed with acute kidney injury. The physician ordered lab work to be done. The nurse expects which of the following abnormal labs to be present in this client with acute kidney injury?
Arterial HCO3-34, 22 to 28
K- 5.7; 3.6 to 5.2. Mg- 3.1 1.7 to 2.2
Creatinine – 0.9; BUN- 12
Phosphorus- 2.2; calcium- 12
A nurse is caring for a client comma home self identifies as a female End also not as sex is male which of the following most the nurse take note
Identify and address the client only by their natural sex gender
demonstrates respect’s for clients non-conforming gender identity
facilitate access to appropriate healthcare providers
be aware of individualised healthcare needs
A client is preparing for discharge following an open radical prostatectomy procedure. which of the following would the nurse not include in the discharge teaching?
use a stool stuff nuts will avoid straining with bowel movements
lift less than 15 lab for the next 6 hours
shower for the first few weeks rather than soaking in the bath
pulled this terrible stripe of the incision when they begin lifting on the edge
The nurse is assessing a client who has a translator resection of the prostate procedure which of which knew finding is the greatest concern?
Client urine output looks like ketchup
clients report pain to be 4 out of 10
client has urine output or 50CC per hour
client has an indwelling catheter and report urge to void
Based on American Cancer society recommendations, what does the nurse teach the patient about screening for prostate cancer?
Beginning at age taxi all men should have an annual digital rectal examination
men that have a prostate specific antigen blood test does not require a digital rectal exam
men with multiple first-degree young relatives with prostate cancer he at early age show discuss screening with their healthcare provider at age 40
Asian -American men should start screaming at 55 years of age
Did nurse is providing education regarding the risks of chlamydia infection.
infertility
pelvic inflammatory disease
ectopic pregnancy
recurring outbreaks
An older adult client is being treated for Endometrium cancer. which of the following is the nurse expect to find in the clients record that was?
pelvic pain
nausea and anorexia
postmenopausal uterine bleeding
vaginal discharge or bleeding
A nurse is caring for a client who has recently been diagnosed with erectile dysfunction. Which of the following are treatment options for this disorder?
Phosphodiesterase-5 (PDE-5) inhibitor
Exercise
Blood pressure control
Penile transplant
A nurse is preparing to administer lisinopril 30 mg PO now. Available is lisinopril 20 mg/tablet. How many tablet(s) should the nurse administer?
0.5
1
1.5
2
The nurse is reviewing the laboratory results for a client with metastasis of prostate cancer to the bone. Which elevated level does the nurse expect to see?
Alpha-fetoprotein
Blood urea nitrogen
Serum alkaline phosphatase
Serum creatinine
You are caring for a client who was diagnosed with syphilis. Which of the following medications are used for treatment?
Benzathine penicillin G
Vancomycin
Ampicillin
Gentamycin
Which of the following is not considered a risk factor for the development of prostate cancer?
Age
Race
Activity level
Genetics
A medication order states administer furosemide 30 mg IM stat. Available is furosemide 100 mg/10 mL. How many mL should the nurse administer?
1.5
2
3
6

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51. A nurse is caring for an older adult client who has hypothyroidism. Which of the following findings should the nurse expect? 1. Bradycardia 2. Weight-loss 3. Increased temperature 4. Restlessness 52. A nurse is contributing to the plan of care or a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? 1. Administer antibiotic therapy before culturing the client’s wound. 2. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client’s room. 3. Discard soiled wound care supplies in a trash receptacle outside the client’s room. 4. Place the client in a private room with a private bathroom. 53. A nurse is assisting a provider with removing a client´s lower-leg cast. Which of the following statements by the nurse is appropriate? 1. ´´You should avoid elevating your leg while sitting.´´ 2. ´´You can expect your leg muscles to look a little swollen.´´ 3. ´´You should hold still to prevent injury to your skin.´´ 4. ´´You can expect to feel pressure when we cut the cast.´´ 54. A nurse is reinforcing teaching with a client and her partner about performing chest physiotherapy at home. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I will need to change my position multiple times during the procedure.´´ 2. ´´I will wear a sweatshirt during the procedure.´´ 3. ´´I should eat a small meal prior to the procedure.´´ 4. ´´I should take a prescribed bronchodilator following the procedure.´´ 55. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? 1. Offer an analgesic medication. 2. Request the client to be NPO. 3. Administer a glycerine suppository. 4. Ambulate the client in the hallway. 56. A nurse is reviewing the results of a client´s fecal occult blood screening test. Which of the following findings from the client’s history should the nurse identify as potentially causing a false-positive result? 1. The client has a history of breast cancer. 2. The client consumed citrus juice 3 days before the test. 3. The client takes ibuprofen for headaches. 4. The client had a hemorrhoidectomy 1 year ago. 57. A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include? 1. Leave doors slightly ajar. 2. Use low-wattage light bulbs. 3. Place throw rugs over electrical cords. 4. Mark the edges of steps. 58. A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? 1. Cover the paid prior to use. 2. Fill the pad with sterile water. 3. Use safety pins to secure the pad in place. 4. Apply the pad for 45 min at a time. 59. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I should place an aspirin in the pouch to eliminate odor.´´ 2. ´´I should avoid broccoli and chewing gum.´´ 3. ´´I should clean around the stoma with moisturizing soap.´´ 4. ´´I should decrease the amount of fresh fruit in my diet.´´ 60. A nurse is supervising an assistive personnel(AP) providing care for a group of clients. For which of the following actions should the nurse intervene? 1. The AP plans to assist a client who had hip arthroplasty to a bedside commode. 2. The AP plans to turn a client who has paraplegia every 2 hr. 3. The AP prepares to provide wound irrigation to a client who has a decubitus ulcer. 4. The AP prepares to obtain the blood pressure of a client who had peritoneal dialysis. 61. A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take? 1. Implement contact precautions. 2. Maintain the client in a supine position. 3. Apply petroleum jelly to the client´s nares. 4. Initiate precautions. 62. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects? 1. Agitation 2. Ringing in ears 3. Rhinitis 4. Metallic taste 63. A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? 1. Changed mental status 2. Diminished reflexes 3. WBC count 9,000/mm3 4. Temperature 37.3 degrees celsius(99.1 degrees Fahrenheit) 64. A nurse is reinforcing teaching with a group of clients who are at risk for coronary heart disease due to hypercholesterolemia. Which of the following information should the nurse include in the teaching? 1. Include fish in the diet two times per week. 2. Increase intake of dairy products 3. Limit servings of meat per meal to 113 to 170 g(4 to 6 oz). 4. Cook with coconut oil. 65. A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take? 1. Apply a heat pack to the client´s lower abdomen. 2. Administer an enema to the client. 3. Give the client a clear liquid diet. 4. Place the client in semi-Fowler’s position. 66. A nurse on a medical-surgical unit is caring for an older adult client who has developed due to a urinary tract infection. A member of the client’s family tells the nurse not to perform any ´´heroic measures´´ to keep the client alive. Which of the following responses by the nurse is appropriate? 1. ´´Ýou should contact the client’s attorney to document your wished legally.´´ 2. ´´Why do you believe treatment would not benefit the client?´´ 3. ´´The client’s condition is not critical enough to discuss these issues.´´ 4. ´´Let me check the client’s medical record for advance directives.´´ 67. A nurse is interpreting the results of a tuberculin skin test for a group of clients who received this test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result? 1. A client whose injection site is scabbed. 2. A client whose injection site has an elevated area measuring 15 mm. 3. A client whose injection site is ecchymotic 4. A client whose injection site is firm and measures 3 mm. 68. A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? 1. Keep both arms below the level of the client’s heart. 2. Obtain blood pressure readings using the client’s right arm. 3. Limit range-of-motion exercises with the affected arm. 4. Use the client’s left arm to obtain blood samples. 69. A nurse is collecting data from a female client who is postmenpausal. Which of the following should the nurse identify as a risk factor for the development of osteoporosis? 1. Long-term use of prednisone 2. Monthly vitamin B12 injections 3. Congenital heart murmur 4. History of kidney stones 70. A nurse is reviewing a client’s medical record. Which of the following findings is the priority for the nurse to report? 1. Urine output 200 mL/8hr 2. Potassium level 6.2 mEq/L 3. Abnormal hepatoiminodiacetic acid(HIDA) scan 4. A client’s rating of ear pain as 5 on a scale from 0 to 10. 71. A nurse is caring for a client who has a new diagnosis of tuberculosis(TB). The client asks the nurse why she needs to take four different anti tuberculosis medications. Which of the following replies should the nurse make? 1. ´´Taking several anti tuberculosis medications will protect your liver from toxic effects.´´ 2. ´´People who have a severe form of TB need several anti tuberculosis medications, but those who have less severe TB need just one medication.´´ 3. Adverse effects occur more often and are more severe when you take only one anti tuberculosis medication.´´ 4. ´´The organism that causes TB becomes resistant to anti tuberculosis medications when you only take one medication.´´ 72. A nurse is assisting with the plan of care or an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? 1. Monitor the client for weight loss. 2. Check the client for increased hypopigmentation under the patch. 3. Advise the client about increased dry mouth. 4. Inform the client of the adverse effect of diarrhea. 74. A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? 1. Close mouth when sneezing. 2. Resume exercising in 10 days. 3. Plan to shampoo hair in 1 week. 4. Drink fluids through a straw. 75. A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the interventions should the nurse take? 1. Decrease the client’s protein intake. 2. Encourage the client to eat a diet rich in whole grains. 3. Cleanse the client’s toothbrush with hydrogen peroxide. 4. Use a disposable razor to shave. 76. A nurse is assisting with the care of a client who is postoperative and has received fentanyl for pain management. In the event the client develops respiratory depression, the nurse should make sure that which of the following medications is available to administer? 1. Atropine 2. Naloxone 3. Flumazenil 4. Acetylcysteine 77. A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include the teaching? 1. Eliminate dairy products. 2. Eat lighter, low-calorie foods first. 3. Limit fluid intake during meals. 4. Consume three regular meals daily. 78. A nurse is caring for a client who had a colon resection 2 days ago. When entering the client’s room, the nurse sees a protrusion of tissue from the incision. Which of the following is the appropriate nursing intervention? 1. Place the client on her left side. 2. Place the client in Trendelenburg position. 3. Cover the site with a sterile, saline-soaked dressing. 4. Cover the wound with a dry, sterile dressing. 79. A nurse is caring for a client who has chronic kidney disease. Which of the following interventions is appropriate? 1. Administer NSAIDs for discomfort. 2. Obtain the client’s daily weight. 3. Monitor the client for hypokalemia. 4. Offer the client a high-protein diet. 80. A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? 1. Hold the client’s finger in a dependent position. 2. Clean the client’s finger with hexachlorophene. 3. Apply the first drop of blood to the test strip. 4. Prick the central tip of the client’s finger. 81. A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include? 1. Plan to eat a snake 6 hr after insulin administration. 2. Warm the vial to dissolve any crystals that develop. 3. Store opened insulin vials at room temperature for up to 4 weeks. 4. Keep unopened insulin vials in the freezer. 83. A nurse is reinforcing discharge instructions with a client who is taking oral iron supplementation for anemia. Which of th4e following statements by the client demonstrates an understanding of the teaching? 1. ´´ I should notify my doctor if my stools turn black.´´ 2. ´´I should drink my liquid iron supplement undiluted.´´ 3. ´´I should take my supplement with an antacid to prevent an upset stomach.´´ 4. ´´I should increase my fiber intake while taking this supplement.´´ 84. A nurse is providing directions to an assistive personnel about moving a client up in bed. Which of the following statements should the nurse include? 1. ´´Place a pillow under the client’s head prior to repositioning.´´ 2. ´´Face in the direction of the client’s movements.´´ 3. ´´Keep your feet close together while moving the client.´´ 4. ´´Move the client’s arms to his sides prior to repositioning.´´ 85. A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? 1. Replace the unit when the drainage chamber is full. 2. Clamp the tube for 30 min every 8 hr. 3. Monitor for at least 150 mL of drainage every hour. 4. Pin the tubing to the client’s bed sheets. 86. A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next? 1. Check whether the bleeding has stopped. 2. Maintain direct pressure over the site. 3. Obtain a radial pulse. 4. Reinforce the dressing over the site. 87. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter(PICC). Which of the following statements by the client indicates an understanding of the teaching? 1. ´´It’s okay to get the device wet when I shower.´´ 2. ´´I will wear an arm immobilizer to prevent dislodgement of this device.´´ 3. ´´I should pull the dressing away from the insertion site when I change it.´´ 4. ´´I will monitor my temperature for fever while I have this device.´´ 88. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? 1. Apply foam handles to the client’s eating utensils. 2. Have an assistive personnel feed the client. 3. Obtain a referral for physical therapy. 89. A nurse is reinforcing teaching with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? 1. Oil-based ointment 2. Benzoyl peroxide 3. Phototherapy 4. Dermabrasion 90. A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider? 1. The client’s fingers are cool to the touch. 2. The client´s capillary refill is 3 seconds. 3. The client reports increased pain at the area of the fracture. 4. The client reports severe itching under the cast. 91. A nurse is collecting data from a client who has Graves´ disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos? 92. A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou test. Which of the following actions should the nurse take? 1. Place the client in the Sims´ position. 2. Instruct the client to avoid using tampons following the procedure. 3. Reinforce teaching that the procedure involves dilation of the cervix. 4. Instill a vaginal cream prior to the procedure. 93. A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated? 1. Recent onset of confusion 2. Decrease in pulse rate 3. Increase in blood pressure 4. Cool, clammy skin 94. A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan of care? 1. Instruct the client to shave with a disposable razor. 2. Initiate protective isolation for the client. 3. Administer ibuprofen for mild headache. 4. Check the client for ecchymosis. 95. A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? 1. Ammonia 55 mcg/dt. 2. Bilirubin 1.0 mg/dL 3. Aspartate aminotransferase 34 units/L 4. Platelets 60,000/mm3 96. A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? 1. Apply restraints to the client 2. Place the client in the prone position 3. Insert a tongue blade into the client’s mouth 4. Administer an IV bolus of lorazepam 97. A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority? 1. Moderate amount of serosanguineous drainage on dressings. 2. Report of a sore throat. 3. Serum calcium level 9.2 mg/dL. 4. Oral temperature 39 degrees celsius(102.2 degrees Fahrenheit). 98. A nurse on a medical-surgical unit has just received change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel? 1. Reinserting an NG tube for a client who requires gastric decompression. 2. Performing a closed catheter irrigation for a client who is postoperative. 3. Bathing a client who has hemiparesis following a stroke 4. Showing a client who has a new colostomy how to empty the pouch 99. A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home? 1. Oropharyngeal airway 2. Yankauer catheter 3. Water-soluble lubricant 4. Sterile gloves 100. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? 1. ´´I should round the corners of my toenails with a nail file to prevent ingrown nails.´´ 2. ´´I should use my wrist to test the temperature of the water before bathing. ´´ 3. ´´I should apply a heating pad to my feet every night to help with circulation.´´ 4. ´´I should put lotion between my toes every day to prevent dryness and cracking.´´

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Inpatient: A Psychiatric Story
Day 1
You’ve spent a week lying in bed, getting up intermittently to feed yourself. When the phone rings, you ignore it. You don’t know if you still have a job, and you don’t particularly care either. The world is too draining for that.
You lost a friend two weeks ago. Your cat, Cassandra, passed away. There were signs of sickness the night before, but you decided you would take her to the vet the following day if it still looked bad.
She died in the middle of the night.
You’re in a spiral of indifference and hate, as even the most basic of your routines – waking up, checking her food and water – have been interrupted. Occasionally you move in the direction of her food, only to remember. You’ve spent days upon days remembering.
Your feelings are too intense to rely on their messages. You’ve lost hope. You’re suicidal, and the last place to turn is a hospital.
You pick a hospital. Somewhere you aren’t known – somewhere you haven’t been before. You call a taxi.
You’re there.
The walls are adorned with large colourful murals. One section is a picturesque landscape with the word “RECOVERY” in a bold font. You can barely remember the events of the day or how you made it here.
The receptionist sits behind a glass window, and she looks to you. “How may I help you?”
You stutter for a moment, struggling to find words. “I, um, need to talk to a doctor.”
You exchange basic information and provide proof of health insurance. She verifies your address and emergency contacts. A large man takes your bag and leads you to an isolated area in the hospital. He wears a blue shirt with “Protection Services” written on the back. The security guard raises his ID to a sensor beside the wide door. It beeps, and he opens the door. You walk in, and it shuts behind you.
You just arrived in the ER. You know you’re going to wait a while – but you don’t know how long.
The room is bland and empty with many rows of chairs. Each chair is divided by an arm rest. A single TV on the wall plays a repetitive 24-hour news station. Opposite the TV is the nursing station – a wall lined with windows and a locked door.
There is a woman sitting cross-legged underneath the TV. She stares at her phone, and a charger is plugged into a wall outlet beside her.
You grab yourself a seat and give the wall a good stare.
As you fixate on the wall, or nothing in particular, your mind wanders. You try to piece together what is happening and why you came in. The further back you reach into your mind, the harder it is to recall.
Things aren’t that bad, afterall, are they? Wouldn’t it be nice to go home and take a nap?
You long for the doors to be opened so that you can be free. However, you know from experience that they won’t let you leave until you’ve seen a doctor.
Each memory you discover gets lost in the moment, except for the times when you get lost in the memory. You start to wish you had a pen and some paper to write this down, because your recall won’t likely improve by the time you see a doctor.
You have no idea why this is triggering your anxiety. You want to leave. You want to stay. You’re not sure what you’ll say.
Perhaps a nurse has some paper and a pen.
You’ve been in the ER for almost an hour. You hope they haven’t forgotten you.
The TV blares as usual. You think you’ve watched the news cycle repeat at least 5 times so far. You wonder if you can change the channel, but you don’t feel motivated to ask.
You sit down in one of the chairs and pick up one of the newspapers. It’s the free periodical they give out to commuters. You flip through a few pages trying to find something of interest to you.
You try to read, but your mind is too foggy to concentrate. The words melt off the page. You’re better off staring at a wall – it’s way harder to screw that up.
You’ve been in the ER for 2 hours. The boredom and frustration is building, but for the most part you manage to ignore it.
You have fully tuned out the TV. It’s just background noise now. You start to wish you had a handheld video game to play with. You wish you had something that could occupy your mind.
You look through the window in the nursing station. Around 8 people are inside, and they appear to be having a conversation amongst themselves. One of the male nurses laughs as he talks, though you cannot hear what he is laughing about.
How will you get their attention?
You gently knock on the door. You look inside – none of the nurses looked up. It seems that they haven’t even noticed.
You knock again, slightly harder. Still nothing.
You look through the window in the nursing station. Around 8 people are inside, and they appear to be having a conversation amongst themselves. One of the male nurses laughs as he talks, though you cannot hear what he is laughing about.
How will you get their attention?
You slam your fist on the window once.
“What are you doing?!”
A woman with long, dark hair looks up for a moment. She rolls her eyes and stands up. She approaches the door and opens it.
“How can I help you?” she asks, with a superficial cheeriness.
You try to explain, “I am really, really anxious. I’ve been waiting for a long time and I just thought if I could have–”
“We can’t give you Ativan. You have to wait for the doctor to order it for you.”
You shake your head. “I don’t want an Ativan. Can you please listen?”
While you’re talking, the nurse walks back inside and slams the door. You consider slamming your fists and screaming again, but it doesn’t seem like it would help.
A nurse approaches you and tells you that the psychiatrist will see you now. You breathe a sigh of relief and prepare to speak with him.
You follow the nurse to one of the side rooms with an open door and a table in the centre. There are two chairs. You step inside.
“Have a seat. Doctor Marion will be with you shortly.”
Wordlessly, you lower yourself into one of the chairs. You try to shift it gently towards the table, but the chair is quite heavy – perhaps deliberately weighed down. The armrests have no gap between the arm and the seat of that chair. You shrug your shoulders.
A young woman enters the room. Dr. Marion, you presume.
“Hello there, Jessica. I’m Dr. Marion, the resident psychiatrist. I hear you’re not having the best day.”
You nod.
“Tell me a little bit about what brings you in here.”
You respond, “I’m … it’s very hard to say.”
You break eye-contact because connection is too much. You’d rather dissociate yourself away from the situation than face it head-on.
Dr. Marion nods patiently. “Take your time. It’s all right.”
This is your final chance to leave. You can say whatever you want. Once the secret is out, you’ll likely be admitted as an involuntary patient. But if you say too little, you may be denied any help or support at all.
You take a deep breath.
With your eyes fixed on the floor, you try to summon the courage to say something. You are acutely aware of the power the psychiatrist has over you, and the next words you say could get you detained.
It isn’t that you honestly want that. You just don’t know what else to do. And yet at the same time, the part of you that wants to die is fighting the urge to say it.
You force it out. “I… I want to kill myself.”
She nods again. “OK. You want to kill yourself. How long have you felt this way?” Her nonchalant approach would normally seem quite odd, but nothing is normal about this conversation.
It feels like forever, but you know that isn’t true. “A few weeks,” you respond.
“All right. This is very important, so I’m going to ask you a few questions about it.”
Dr. Marion asks, “Why do you want to die?”

You take a deep breath. “I just don’t see another way. Life hurts so much, all the time, and I can’t handle it anymore.”

She responds, “Are there specifics? What makes your life this painful?”

You struggle to find words. Your heart races, and you are overtaken by a heavy shame. As the feeling settles in, you close your arms into your belly and look to the ground.

Dr. Marion says, “I know this is hard to talk about. Take your time.”

You nod slowly. It feels as though your larynx is swelling. You don’t want to say it. You don’t even want to think it.
Dr. Marion asks, “Why do you want to die?”
You take a deep breath. “I just don’t see another way. Life hurts so much, all the time, and I can’t handle it anymore.”
She responds, “Are there specifics? What makes your life this painful?”
You struggle to find words. Your heart races, and you are overtaken by a heavy shame. As the feeling settles in, you close your arms into your belly and look to the ground.
Dr. Marion says, “I know this is hard to talk about. Take your time.”
You nod slowly. It feels as though your larynx is swelling. You don’t want to say it. You don’t even want to think it.
It seems easier to talk around it than to actually talk about it, and if you get the same result – a safe place to rest for a few days – then there is no real upside to talking about it.
“It’s just hard. It’s so hard. I hate myself, and I want it to be over, and I don’t see any reason to go on.”
Dr. Marion nods. “I can see that you’re in a lot of pain. Is there more you can say about that?”
You can’t bear to look at her. “Cassandra was sick. I didn’t take her to the vet in time. She died, and it’s all my fault. I hate myself.”
Dr. Marion nods. “These things can happen, Jessica.”
“You don’t understand. She died because of me. She was the only thing keeping me going, and she died because of me.” You’re shaking now and finding it hard to focus.
“It sounds like you really cared about Cassandra. Pets are like family.”
“You don’t understand,” you say with a trembling voice. “She was the only reason I woke up in the morning. The only reason I didn’t kill myself was because she would end up at a shelter. Now that she’s gone I… I just don’t care anymore.”
“What about the rest of your family?” she asks.
You shake your head. All you can think to say is that they’ll be better off without you. You’ve made enough dramatics for now. You shake your head again, and again.
“Are you close to your parents? Siblings?”
“They will be better off without me,” you retort.
Dr. Marion jots a few things down and then looks at you again. “Do you have any plans to kill yourself?”
You nod, and she asks what it is. You take a deep breath and slowly explain the plan you had. You already own what you need, and you already wrote a note to your loved ones. The only thing left was to go home and do it.
“I think I know what we need to do right now. The most important thing, I think, is to keep you safe tonight.”
Dr. Marion frowns and looks at you sympathetically. “All right. Do you know what a Form 1 is?”
Of course you know what a Form 1 is. You’ve been formed so many times in the past that you couldn’t not know.
She continues, “A Form 1 is a 72-hour psychiatric evaluation. I’m concerned about you, and I think this is the best way to keep you safe. We can work on safety planning and medication while you’re here, and remember that it’s just 72 hours. Not forever.”
Dr. Marion says, “Your nurse will be with you shortly.” She leaves the room. You allow your mind to drift. Being formed used to be a novelty. You remember the first time. You were so terrified of what would happen to you. You were afraid you would never leave the hospital again. Yet, as time moved on with more life and experience, you came to realize that 72 hours was nothing. A couple sleeps, and you’ll head home.
You rest your back against the chair and wait for your nurse. A half-hour rolls by as you stare at the wall. Knowing that you’re somewhere safe for the night brings you a small amount of relief – confusing relief to be honest, as you still want to kill yourself. On some level it is nice to know that people will make sure you stay alive.
The security guard you met earlier walks in holding your backpack and purse. “I need to search and catalogue your belongings. When we’re done, they will stay behind the nursing station to ensure that you’re safe.”
You nod. He puts on two latex gloves and begins rummaging through your belongings. As he removes each clothing item he makes a small note of it on a piece of paper. Underwear here, bra there. He picks out a pair of pyjama pants and puts it in a separate pile. “You can’t have anything with a drawstring,” he says.
He takes your smartphone and charger, and puts it in a small plastic bag. You suppress a laugh when you notice the biohazard symbol on it.
“The laces from your shoes, please.”
The laces? You sigh and proceed to delace your shoes.
“Are you wearing a belt?” he asks.
You nod, and hand the belt over to him too. Your pants are barely clinging to your waist as you use your hands to hold them up.
“OK miss, one last thing.”
Another man who you didn’t see approaches you with a handheld metal detector. “Stand with your arms out,” he orders.
You consider your options.
You nod slowly. You don’t like being ordered around, but snapping at him won’t help.
This entire process always gets you. Supposedly it’s for your own safety, but you don’t normally care in the moment. You turn your eyes and head down to the floor, stretch your arms out, and let him proceed.
You close your eyes as the metal detector passes over your legs and arms. You always hate this part – always. It can’t be over soon enough.
A young white woman walks out of the nursing station and approaches you. “Hi Jessica, I’m Chanelle. I’ll be your nurse until 11:00.”
“Hi Chanelle,” you say while taking one quick glance at her face before watching the floor beneath you again.
She begins walking and you follow her footsteps. “Is this your first time in hospital?” she asks as you approach a pair of locked doors.
You shake your head. “First time at this one,” you say.
“OK. Hopefully here it’s not too different,” she says, seemingly without regard for your past experiences.
She holds her employee ID up to a card reader. It beeps, and she opens the door, holding it for you. You walk ahead of her, and the door slams shut.
“You won’t be down here for too long,” she says. “This is our crisis ER. We’ll try to transfer you soon, but for now you can stay down here.”
The walls are all coated in a dull white paint. As you’re walking you see some doodles and pencil marks on the wall. You follow Chanelle through a simple hallway. You glance into an open room while walking by. There are a few rows of tables, and a few soft chairs. The soft chairs are directed at a television. The TV sits behind a locked glass panel, and it’s currently turned off.
She stops at a door on the other end of the hallway and gestures for you to walk in. You do so. There is a small bed in this room.
You gently lower yourself on to the bed, and you fold your hands together. You fix your eyes on the floor in front of her feet.
Chanelle starts. “I just want to welcome you to the Crisis ER. Here we see patients who are in acute crisis. The first step is stabilizing your crisis. Dr. Marion gave me a quick overview but I always like hearing things directly from the patient.”
“I…” – you pause, you stutter. It has barely sunk in that this is really happening, and yet you’re being asked to tell your story again. You wonder why she can’t just read the notes. “I’m tired,” you say.
“Can you say more about that?” she responds.
You take a deep breath before responding. “My cat is dead. I’m locked in this prison for the next three days. I hate myself. I hate everything about myself, and I don’t see the point of living.”
Chanelle nods. “Right. So you’re having thoughts of suicide?”
“Yes,” you respond quietly.
“Do you have a plan for how you would do it?” she asks.
You find it difficult to explain again – you have forgotten by now how many people asked you this question. Your set your eyes onto the tiled floor as you explain your detailed plan. It takes about a minute to go over the usual “where, when, how” questions. You’re grateful when it’s over.
“That sounds like a really serious plan. How do you think your family would react if you did this?”
Family? You shrug your shoulders. “I figure they’re better off without me.”
“Do you think you’ll try to hurt yourself inside the hospital?”
You think for a moment about how you might accomplish this – you come up with a few creative, plausible solutions. But, would you? You think for a moment more and respond, “No, I don’t think so. Not with everyone watching me.”
Chanelle nods. “I’m very glad you came in. It sounds like you’re dealing with a lot right now. Dr. Marion ordered some Ativan for you. Just come get me if you need any.”
With that, she walks out of the room. You wonder if she found you abrasive. She did leave relatively quickly, but your overall impression is that she’s a kind
In particular, what did you think of the patient’s interactions with the nursing staff?

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