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In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
- A. whole brain death.
- B. heart-lung death.
- C. circulatory death.
- D. higher brain death.
Correct Answer: A
Rationale: Most protocols require two separate clinical examinations, including induction of painful stimuli, papillary responses to light, oculovestibular testing, and apnea testing. Heart-lung and higher brain death have no specific test required. Circulatory death is not a current definition of death in the United States.
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A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality.
- B. leaving the client alone until reality returns.
- C. asking the client to describe what is happening.
- D. telling the client there are no voices.
Correct Answer: C
Rationale: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.
A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
- A. With a physical therapist treating the patient
- B. With a social worker planning for discharge
- C. With another nurse on duty to plan for break time
- D. In the hallway outside the patient's room.
Correct Answer: D
Rationale: Hallway discussions should not occur, because you do not know who is listening, even though it may be a professional discussion.
A 28 year-old male has a diagnosis of AIDS. The patient has had a two year history of AIDS. The most likely cognitive deficits include which of the following?
- A. Disorientation
- B. Sensory changes
- C. Inability to produce sound
- D. Hearing deficits
Correct Answer: A
Rationale: Cognitive changes may include confusion and disorientation.
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client's perspective.
A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:
- A. the client's body has developed tolerance, requiring more drug to produce the same effect.
- B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence.
- C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance.
- D. the client has a dual diagnosis of substance abuse and chronic back pain.
Correct Answer: A
Rationale: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the person's social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.