NR-226 Patient Care Fundamentals - Set 5 - Part 1

Correct Answer: Denial of an unacceptable external reality

Denial rejects an unacceptable reality and substitutes a more tolerable explanation. Calling a confirmed heart attack indigestion and asking to leave shows the client refusing the diagnosis rather than redirecting or excusing a feeling. Option b is incorrect because regression means behavior slides back to an earlier stage, such as an adult becoming helpless or a toilet-trained child wetting the bed. This client's behavior has not changed that way. Option c is incorrect because displacement redirects a real emotion toward a safer person or object while the person still owns it. Nothing in the scenario shows anger being aimed anywhere. Option d is incorrect because rationalization supplies a plausible excuse for a behavior the person has already chosen, such as blaming parking for missed rehabilitation. Here the diagnosis itself is being rejected.

Correct Answer: Type four, indicating the ideal form

The Bristol scale places smooth, soft, sausage-shaped stool at type four, the form that reflects healthy transit time and water content. Types three and four are both normal, and four is the goal. Option a is incorrect because type one is separate hard lumps resembling nuts that are difficult to pass. That form signals very slow transit, the opposite of the soft shaped stool described here. Option b is incorrect because a type two stool is sausage-shaped but visibly lumpy, marking mild to moderate constipation. Smoothness is the feature that separates the two, and this stool was smooth. Option d is incorrect because type six describes fluffy mushy pieces with ragged edges, a fast-transit pattern classed as mild diarrhea. Nothing in the documentation suggests loose fragments; the stool held its shape.

Correct Answer: Grandma died, and her body does not work anymore

Preschoolers see death as reversible and think literally, so the nurse teaches the plain word died with a concrete body explanation. Euphemisms about sleep, being lost or being taken create new fears in a literal child. Option b is incorrect because a literal preschooler who hears that death is sleep concludes that sleeping is dangerous. Bedtime terror and resistance to naps predictably follow this particular euphemism. Option c is incorrect because saying someone was lost invites a young child to ask whether she can be found. The phrase also skips the plain word the child needs in order to grasp what happened. Option d is incorrect because making a deity the agent of the death frightens children, who then wonder who will be taken next. It also imposes a theology the family may not hold.

Correct Answer: Notify the organ procurement organization per policy

The hospital must notify the organ procurement organization of every death and imminent death, and the organization determines suitability. Only an organization representative or a trained designated requestor may approach the family about donation. Option a is incorrect because the request must come from a procurement representative or a trained designated requestor. Untrained approaches lower consent rates and add distress, so the bedside nurse does not open the subject. Option b is incorrect because devices stay in place when donation is under consideration, and ordered physiologic support continues so the organs remain viable. Pulling the tube and lines forecloses the option entirely. Option d is incorrect because notification is a federal requirement that does not depend on whether a relative asks. Waiting for the spouse to speak first can let the window for organ recovery close.

Correct Answer: Sustained cortisol suppressing immunity and healing

Chronic stress keeps cortisol elevated, which damps cytokine production and lymphocyte function while reducing fibroblast activity and collagen synthesis. That combination explains frequent infections, reactivated herpes simplex and a wound that gains strength slowly. Option a is incorrect because catecholamines briefly move leukocytes out of vessel walls and toward likely injury sites during acute stress. That short-lived boost cannot explain a year of infections and a stalled wound. Option b is incorrect because parasympathetic activity returns when a demand has ended, and this client's strain has not ended. Vagal recovery restores digestion and slows the heart; it does not weaken defenses. Option c is incorrect because antidiuretic hormone conserves water and lowers urine output, which is a fluid balance effect. Water retention has no bearing on recurrent infection or the tensile strength of a healing wound.

Correct Answer: A positive interferon-gamma release assay

Anti-tumour necrosis factor agents reactivate latent tuberculosis, so a positive interferon-gamma release assay must be reported and treated before the first dose. Starting the biologic first risks disseminated infection in a suppressed immune system. Option a is incorrect because a raised C-reactive protein simply confirms active inflammation, which is the reason the drug was ordered. It is expected in a Crohn's flare and does not delay treatment. Option b is incorrect because a haemoglobin still within the reference range needs monitoring, not a phone call. Mild anaemia is nearly universal in inflammatory bowel disease and is addressed alongside therapy rather than ahead of it. Option d is incorrect because a penicillin allergy has no bearing on a monoclonal antibody, which shares no structure with beta-lactam antibiotics. The screening that governs this drug concerns tuberculosis and hepatitis B.

Correct Answer: Screening should begin now at age forty-five

Both the American Cancer Society and the United States Preventive Services Task Force now set the starting age for average-risk adults at forty-five, because incidence in younger adults has been climbing. Option b is incorrect because fifty was the old threshold, abandoned by the American Cancer Society and then by the Task Force. Waiting five more years would miss the age group in which cases are rising fastest. Option c is incorrect because no major guideline names sixty as a starting point. Screening actually stops around seventy-five for most adults, with individualised decisions after that, so sixty falls in the middle of the recommended span. Option d is incorrect because early colorectal cancer produces no symptoms at all. Screening exists precisely to find disease in people who feel well, and waiting for bleeding means finding the tumour late.

Correct Answer: Dim the lights and limit evening noise

Adjusting the environment is a comfort measure within the assistive personnel's scope and needs no clinical judgment. Reducing light and noise supports sleep, which breaks the loop between poor sleep and continued activation of the stress axis. Option a is incorrect because instructing a client in a relaxation technique is teaching, which the registered nurse retains. Experience does not extend an assistant's scope to include client education. Option b is incorrect because evaluation is the nursing process step that judges whether an outcome was met. Deciding that anxiety fell after relaxation calls for interpretation the nurse alone is licensed to perform. Option c is incorrect because gathering and interpreting data about coping and support is assessment, the first step of the nursing process. Collecting a routine measurement differs entirely from forming a judgment about coping.

Correct Answer: Drink extra fluids and take the ordered laxative

Retained barium hardens and can cause impaction or obstruction, so the client pushes fluids and takes the prescribed laxative to clear it. Stool will look chalky white until the contrast has passed. Option a is incorrect because restricting fluid is exactly backward. Water is what keeps the contrast soft enough to move through the colon, and cutting intake makes a hardened barium impaction more likely. Option b is incorrect because a laxative is deliberately ordered after this study rather than withheld. Waiting a week without evacuating the contrast is how retained barium turns into an obstruction requiring intervention. Option d is incorrect because barium lightens the stool instead of darkening it, producing a chalky white appearance. Black tarry stool would signal upper gastrointestinal bleeding, an entirely different finding that must be reported.

Correct Answer: Stop the procedure and remove the finger

Stretching the rectal wall stimulates the vagus nerve and can drop the heart rate and blood pressure toward syncope or arrest. Withdrawing the finger removes the stimulus at once, which is the priority before anything else. Option b is incorrect because lubricant reduces friction and mucosal trauma but does nothing about vagal stimulation. Continuing in any form keeps the rectum distended and lets the bradycardia deepen toward a dangerous rhythm. Option c is incorrect because bearing down is itself a Valsalva manoeuvre, adding a second vagal insult to a client whose pulse is already falling. Straining is exactly what this client must avoid right now. Option d is incorrect because an oil retention enema is the softening step that belongs before disimpaction is attempted at all. Instilling anything rectally now prolongs the stimulation the nurse is trying to end.

Correct Answer: Maladaptive coping despite short-term relief

Coping is judged by its consequences on function. Alcohol brings brief relief but fragments sleep, and withdrawal from friends and missed appointments show the client losing his support and his care, which marks the pattern maladaptive. Option a is incorrect because focus and outcome are separate axes. Even where a stressor cannot be changed, an emotion-focused strategy must still preserve health and relationships, and drinking to sleep destroys both. Option c is incorrect because problem-focused coping acts on the demand itself, through steps such as applying for another position or asking the manager for a plan. Alcohol changes nothing about the demotion. Option d is incorrect because defense mechanisms are largely unconscious mental operations, while this client knowingly reaches for a drink each night and can describe why. Deliberate behavior belongs under coping instead.

Correct Answer: Hospice care in her own home

Hospice fits a client who has a limited prognosis and has chosen comfort over cure for the terminal illness. Most hospice care is delivered wherever the client lives, including a private home. Option b is incorrect because palliative care given with chemotherapy keeps the treatment this client has asked to stop. She would still benefit from palliative principles, but hospice is the program that matches stopping treatment. Option c is incorrect because rehabilitation aims at restoring function through intensive therapy, a goal that costs energy this client wants to spend elsewhere. Nothing she described points toward a functional recovery program. Option d is incorrect because respite admission is a short stay that relieves an exhausted caregiver. It is a component within hospice rather than the ongoing service this client is asking about.

Correct Answer: It means care matching the client's priorities

A good death is defined by the person dying, so the team asks what matters most and shapes the plan around it. Quality of life at the end is measured against the client's own goals. Option a is incorrect because withholding medication would leave pain, breathlessness and restlessness untreated. Symptom control is one of the strongest contributors to a peaceful death rather than something to be avoided. Option b is incorrect because maximum length of survival is a curative goal that often costs comfort, time at home and the chance to say goodbye. Many clients rank those things above extra days. Option c is incorrect because naming one location as the right one ignores what this client wants. A setting becomes correct only when it matches the person's own wishes, and preferences vary widely.

Correct Answer: When things have been hard before, what has helped you?

Asking what has helped before uncovers the client's established coping repertoire, which is what she will reach for under load. Reinforcing coping that already works is far more effective than introducing new strategies now. Option a is incorrect because raising placement leaps to a solution the client has not asked about and may hear as judgment. The nurse still knows nothing about how she has coped. Option b is incorrect because that closed question carries a judgment inside it and invites a defensive yes. Normalizing the burden this way shuts down the very disclosure the nurse needs. Option d is incorrect because offering an aide is a reasonable later step, yet it supplies a resource before the assessment shows which resource fits. Intervention without appraisal data often misses the real stressor.

Correct Answer: Adventitious crisis affecting an entire community

Adventitious crises arise from unplanned, often community-wide disasters or violence, including hurricanes, floods, tornadoes and mass casualty events. A tornado that destroys a town disrupts many families at once and fits this category. Option b is incorrect because a maturational crisis grows from an expected life transition the person cannot negotiate, such as retirement or becoming a parent. A tornado belongs to no developmental stage. Option c is incorrect because situational crises hit an individual or a single family, as with a job loss, divorce or a house fire. The scale here is a whole town, not one household. Option d is incorrect because developmental is another name for maturational, so this choice repeats the same wrong idea in different words. Expected change is exactly what a tornado is not.

Correct Answer: Crohn's disease of the terminal ileum

Skip lesions with rectal sparing, right lower quadrant pain, non-bloody diarrhoea, marked weight loss and a perianal fistula all follow from transmural inflammation of the terminal ileum, which is the signature of Crohn's disease. Option a is incorrect because ulcerative colitis always begins in the rectum and spreads upward without interruption. Normal rectal mucosa and intervening healthy segments rule it out, and the stool of colitis is characteristically bloody. Option c is incorrect because irritable bowel syndrome is a functional disorder of a structurally normal bowel. Weight loss, a fistula and visible endoscopic lesions are all red flags that argue against that diagnosis. Option d is incorrect because diverticular disease produces outpouchings in the left colon and typically presents in later life with left-sided pain. It does not tunnel to the perianal skin or skip along the small bowel.

Correct Answer: Coach the graduate that at-least statements minimize loss

Any sentence that opens with at least compares the loss and tells the griever to feel grateful rather than sad. Coaching the new nurse toward an open invitation keeps the widow talking instead of closing her down. Option a is incorrect because praising the statement reinforces a habit that shuts grieving people down. What sounded comforting to the graduate lands on the widow as an instruction to be grateful. Option b is incorrect because charting support that was not actually provided misrepresents the encounter. The record would then show an intervention while the underlying communication problem goes uncorrected for the next family. Option d is incorrect because defending the graduate to the widow makes her manage someone else's feelings while grieving. The correction belongs to the preceptor and the new nurse, away from the bedside.

Correct Answer: Stop the removal and leave everything in place

In a medical examiner case all lines, tubes and devices stay in place, the body is not washed, and clothing is preserved as evidence. Stopping the removal protects the investigation and the record. Option a is incorrect because a medicolegal autopsy proceeds by statute and the family cannot decline it. Seeking consent misinforms them about their choices and delays the action that actually preserves the evidence. Option b is incorrect because washing destroys material the examiner may need, including trace evidence on the skin. Routine cleansing belongs to an ordinary death, and this one has been referred for investigation. Option c is incorrect because documentation cannot repair a removal that should never have occurred. The nurse records precisely what remained in place, which is only possible if the devices are still there.

Correct Answer: Notify the surgeon about the stoma immediately

A dusky or purple stoma signals that the blood supply has been compromised and the tissue is becoming ischaemic. This finding needs surgical evaluation without delay, because a necrotic stoma requires operative revision. Option b is incorrect because warmth does nothing for a stoma whose arterial supply is obstructed, and waiting an hour wastes the window in which the bowel might still be salvaged surgically. Option c is incorrect because documentation belongs after the report, not instead of it. Routine care is the correct response to a pink, moist stoma with slight oozing, which is not what this nurse is looking at. Option d is incorrect because covering the stoma hides the very finding that must be seen, and repositioning treats no part of an interrupted blood supply. Any constricting appliance should come off rather than go back on.

Correct Answer: Unchanged grief that has disabled her functioning

Normal grief attenuates and function returns. Grief that remains at full intensity beyond a year and keeps an adult from working and from entering a room meets the impairment and duration pattern of prolonged grief disorder. Option a is incorrect because tears when a mother talks about her child are expected at any point after the death. Weeping tells the nurse she is grieving, not that the grief has become a disorder. Option b is incorrect because pangs of yearning separated by stretches of ordinary functioning describe the wave pattern of uncomplicated grief. Waves that pass are evidence of movement, which is exactly what prolonged grief lacks. Option c is incorrect because briefly sensing a deceased person is common and benign among the bereaved. Nurses sometimes mistake it for a psychotic feature, but on its own it carries no diagnostic weight here.