Homework Lance
1. In selecting alternative therapies, the nurse recognizes that therapeutic touch may be most effective with a:
1.
Premature infant
2.
Headache sufferer
3.
Pregnant woman
4.
Psychiatric client
ANS: 2
Studies have found that therapeutic touch is effective in reducing headache pain. Clients such as premature infants, who are sensitive to energy repatterning, may need to avoid therapeutic touch. Clients such as pregnant women, who are sensitive to energy repatterning, may need to avoid therapeutic touch. Persons who are sensitive to human interaction and touch (e.g., those who have been physically abused or have psychiatric disorders) may misinterpret the intent of the treatment and may feel threatened and anxious by the treatment.
DIF: A REF: 779 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
2. The nurse is preparing a presentation on alternative therapies for a community group. The nurse should identify that herbal therapies are:
1.
Approved by the Food and Drug Administration, under the Food, Drug, and Cosmetic Act
2.
Sold as medicines in most stores because they lack major side effects
3.
Allowed to be packaged as dietary supplements if they are without health claims
4.
Consistent in their standards for concentrations of major ingredients and additives
ANS: 3
The Dietary Supplement Health and Education Act passed in 1994 allows herbs to be sold as dietary supplements if there are no health claims written on their labels. Herbal medicines have not undergone the same rigorous testing as pharmaceuticals have; therefore the majority have not received approval for use as drugs. Many herbal medicines are sold as foods or food supplements in health food stores and through private companies because they do not have FDA approval to be sold as a drug. When herbal medicines are developed, concentrations of the active ingredients have been found to vary considerably. Not all companies follow strict quality control and manufacturing guidelines, which set standards for acceptable levels of pesticides, residual solvents, bacterial levels, and heavy metals.
DIF: A REF: 781 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
3. The client asks the nurse about different herbal therapies that may promote physical endurance and reduce stress. Based on the client’s request, the nurse provides information on:
1.
Ginseng
2.
Ginger
3.
Echinacea
4.
Chamomile
ANS: 1
Ginseng is believed to have an effect of increased physical endurance, balancing of the body, and increasing resistance to stress. Ginger is known for its effect as an antiemetic. Echinacea is known for stimulation of the immune system and as an antiinflammatory and antibacterial agent. Chamomile is believed to have an antiinflammatory, antispasmodic, and antiinfective effect.
DIF: A REF: 782 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
4. The nurse recognizes that which one of the following statements is correct concerning complementary and alternative medicine?
1.
One third to one half of the U.S. population uses one or more forms of alternative therapy.
2.
Insurance coverage is available at the same amount as for traditional medicine.
3.
Use of alternative therapies is still not incorporated into medical journals.
4.
Use of alternative therapies is primarily by those who are less educated or in a lower socioeconomic group.
ANS: 1
Between one third and one half of the population in the United States uses one or more forms of complementary or alternative medicine. Insurance coverage of complementary and alternative medicine is increasing, but it is not available at the same amount as for traditional medicine. The interest in complementary and alternative medicine is evident in the increased number of articles about it in respected medical journals and the development of several journals that specifically focus on complementary and alternative medicine. Typically those who use alternative therapies are professional, well-educated, and from a higher socioeconomic standing.
DIF: A REF: 772 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
5. The nurse is aware of the positive responses that may be obtained with the use of alternative therapies. A benefit that the client can gain from relaxation therapy is a decrease in:
1.
Receptivity
2.
Peripheral skin temperature
3.
Oxygen consumption
4.
Alpha brain activity
ANS: 3
The relaxation response is characterized by decreased heart and respiratory rates, decreased blood pressure, decreased oxygen consumption, and increased alpha brain activity and peripheral skin temperature. A cognitive benefit of relaxation therapy is increased receptivity (i.e., the ability to tolerate and accept experiences that may be uncertain, unfamiliar, or paradoxical). Relaxation therapy increases peripheral skin temperature, not decreases it. Relaxation therapy increases alpha brain activity, not decreases it.
DIF: A REF: 775 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
6. In selecting an appropriate alternative therapy, the nurse knows that the client who may benefit the most from the passive type of relaxation is one who is experiencing:
1.
Hypertension
2.
Terminal cancer
3.
Work-related stress
4.
Dysfunctional grieving
ANS: 2
Passive relaxation is useful for persons for whom the effort and energy expenditure of active muscle contraction lead to discomfort or exhaustion, such as the person with terminal cancer. Relaxation has been shown to contribute significantly to cancer palliative care. The person with hypertension would not require the passive type of relaxation. The person with work-related stress would not require the passive type of relaxation. The client experiencing dysfunctional grieving would not require the passive type of relaxation. Therapeutic touch has been found effective in improving the mood in bereaved adults.
DIF: A REF: 776 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
7. In selecting an appropriate alternative therapy, the nurse knows that the client who has Raynaud’s disease with intermittent peripheral ischemia may benefit the most from:
1.
Relaxation therapy
2.
Imagery
3.
Biofeedback
4.
Acupuncture
ANS: 3
Biofeedback techniques are used to assist individuals in learning how to control specific autonomic nervous system responses. With Raynaud’s disease, clients experience intermittent vasospastic attacks of small arteries and arterioles of the hands (most commonly) and/or the feet. Biofeedback can be used to control this autonomic response. Relaxation therapy is not the best selection of an alternative therapy for the client with Raynaud’s disease. Imagery has not been proven to help the client with Raynaud’s disease. Acupuncture is not the best selection of an alternative therapy for the client with Raynaud’s disease. Acupuncture is more frequently used to treat pain.
DIF: A REF: 778 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
8. A nurse needs to be alert to possible negative responses to biobehavioral therapies. Clients who have reacted negatively have most often experienced:
1.
Aggressive behaviors
2.
Delusions
3.
Insomnia
4.
Loss-of-control sensations
ANS: 4
A person who has a strong fear of losing control, or who has experienced sensations of loss of control, may perceive meditation as a form of mind control and thus may be resistant to learning the technique. Some clients may uncover repressed emotions or feelings they cannot cope with during relaxation and/or biofeedback sessions. A benefit of most biobehavioral therapies, such as meditation, is that it lowers irritability. Aggression is an unlikely response. Delusions are not a result of biobehavioral therapies. Many biobehavioral therapies, such as meditation, reduce insomnia.
DIF: A REF: 777 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
9. A practitioner or client who uses traditional Chinese medicine bases the therapy on the primary concept of:
1.
Yin/yang
2.
Meridians
3.
Six evil senses
4.
Acupoints
ANS: 1
The most important concept of Chinese medicine is the concept of yin and yang, which represent opposing, yet complementary phenomena that exist in a state of dynamic equilibrium. When there is an imbalance in these two-paired opposites, then it is thought that disease occurs. Meridians are the channels of energy that run in regular patterns through the body and over its surface. It is not the primary concept of traditional Chinese medicine. The six evil senses are external causes of disease according to traditional Chinese medicine. They are wind, cold, fire, damp, summer heat, and dryness. This is not the primary concept on which traditional Chinese medicine is based. Acupoints are certain points on the body where special needles are inserted to modify the perception of pain, normalize physiological functions, or treat or prevent disease. Acupuncture is just one healing modality used in traditional Chinese medicine. It is not the primary concept on which traditional Chinese medicine is based.
DIF: A REF: 780 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
10. The nurse is preparing to assist the client with meditation and breathing. In preparing to implement this therapy, the first step is to:
1.
Position the client
2.
Provide a warm environment
3.
Have the client close his/her eyes
4.
Note areas of tension or pain
ANS: 1
The first step in assisting a client with meditation and breathing is to position the client comfortably. A quiet space is required, not necessarily a warm environment. The first step is not to have the client close his or her eyes, but to get the client in a comfortable position in a quiet environment. Furthermore, the client does not have to close his or her eyes to meditate and breathe. The first step is to assist the client into a comfortable position, not to note areas of tension or pain.
DIF: A REF: 777 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
11. During the admission history, the client informs the nurse that she follows a macrobiotic diet. The nurse knows that the client’s diet includes:
1.
Increased meats and other proteins
2.
A 30%/40%/30% protein/carbohydrate/fat ratio
3.
Increased intake of vitamin C and beta-carotene
4.
Whole grains, vegetables, and fish
ANS: 4
A macrobiotic diet is predominantly a vegan diet (no animal products except fish). Emphasis is placed on whole cereal grains, vegetables, and unprocessed foods. A macrobiotic diet does not include meats, only fish and plant proteins. The “Zone” is a dietary program that requires eating protein, carbohydrate, and fat in a 30%/40%/30% ratio. Orthomolecular medicine (megavitamin) diet includes an increased intake of vitamin C and beta-carotene.
DIF: A REF: 773 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
12. The client has a history of gastrointestinal problems and has used herbal remedies in the past. The nurse expects that this client will be taking:
1.
Chamomile
2.
St. John’s wort
3.
Echinacea
4.
Ginkgo biloba
ANS: 1
Chamomile is used for inflammatory diseases of the gastrointestinal and upper respiratory tracts, and for gastrointestinal spasms. It may also be used to treat infections and inflammation of the skin and mucous membranes. St. John’s wort is used to treat mild to moderate depression and viral infections, and to aid wound healing. Echinacea is used to treat upper respiratory tract infections and allergic rhinitis, and to aid wound healing. Ginkgo biloba has been used for many health conditions including Alzheimer’s disease, dementia, eye disease, heart disease, poor circulation, varicose veins, anxiety, and age-related diseases.
DIF: A REF: 782 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
13. A client at the clinic informs the nurse during an examination that he has been taking chaparral as an anticancer agent. The client asks if there is any reason why this remedy should not be taken. The nurse responds accurately when telling the client that chaparral:
1.
Should not be taken with coffee or other caffeinated beverages
2.
May induce veno-occlusive disease
3.
Contains a carcinogenic substance
4.
Is associated with liver toxicity
ANS: 4
Chaparral is an herb used for an anticancer effect. It has no proven efficacy and may induce severe liver toxicity. There are no contraindications for taking chaparral with coffee or other caffeinated beverages. Ephedra should be avoided with the consumption of caffeine. Chaparral does not induce veno-occlusive disease. However, comfrey may do so. Chaparral is not known to contain a carcinogenic substance. Sassafras and calamus may contain a carcinogenic substance.
DIF: A REF: 783 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
14. The nurse’s most informed response to the client’s question “What is a complementary therapy?” would be:
1.
“Relaxation is an example of a complementary therapy.”
2.
“It is any intervention that increases your ability to cope with illness.”
3.
“Massage therapy is complementary to muscle relaxant medications.”
4.
“They are therapies that are used in addition to what your PCP orders.”
ANS: 4
Complementary therapies are those therapies used in addition to conventional treatment recommended by the person’s health care provider. The remaining options, while providing examples, do not thoroughly define the term for the client.
DIF: C REF: 772 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
15. The client asks “Is there anything else we can do to help control my pain?” The nurse’s most informed suggestion concerning complementary therapies is:
1.
“Massage therapy may help you; it certainly helped me.”
2.
“Most complementary therapies will help decrease your pain.”
3.
“Have you ever thought about seeing a chiropractor? Manipulation often helps decrease pain.”
4.
“Acupressure uses appropriately applied pressure to specific body points, thus decreasing pain.”
ANS: 4
Acupressure is a therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function. The remaining options make assumptions concerning the origin of the pain and may suggest inappropriate therapies. It is also inappropriate to include such a personal comment as to refer to one’s own pain.
DIF: C REF: 773 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
16. Which of the following clients is most likely to experience the best response from a complementary therapy?
1.
A 5-year-old receiving a painful injection
2.
A 35-year-old having a diagnostic spinal tap
3.
A 55-year-old being catheterized post surgery
4.
A 15-year-old being casted for a wrist fracture
ANS: 1
While most complementary therapies are successful to some degree with most age groups, most complementary therapies successfully reduced discomfort among children.
DIF: A REF: 772 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
17. Research currently identifies which of the following as the primary reason nurses do not use complementary therapies?
1.
Workloads prevent routine implementation
2.
Client reluctance to participate appropriately
3.
General bias regarding effects of the therapies
4.
Lack of education regarding their appropriate uses
ANS: 4
Nurses’ lack of education about how to apply complementary techniques seems to be a barrier to their use of effective nonpharmacological interventions.
DIF: A REF: 772 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
18. A client is dealing with chronic pain. The nurse suggests implementation of relaxation techniques. The nurse’s most informed response to the client’s question “How is relaxing going to help my pain?” would be:
1.
“What have you got to lose? It could certainly help.”
2.
“It will increase the effectiveness of the pain medication you’re taking.”
3.
“Relaxing has been very helpful for people, especially those in severe pain.”
4.
“Relaxing your muscles is a better way for your body to respond to the pain.”
ANS: 4
Complementary therapies teach individuals ways in which to change their behavior to alter physical responses to stress and improve symptoms such as muscle tension, gastrointestinal discomfort, pain, or sleep disturbances. While one of the options appears too flippant an answer, the remaining options may be true but do not address the question as thoroughly.
DIF: C REF: 775 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
19. Which of the following statements, made by a client experiencing anxiety who practices relaxation techniques regularly, requires follow-up by the nurse?
1.
“I want to share this with my sister; her life is stressful, too.”
2.
“Relaxation gives me a sense of being in control of my anxiety.”
3.
“Relaxation helps me feel less physically tense so my blood pressure is lower.”
4.
“If I practice relaxation techniques often enough, I won’t need my antianxiety medication anymore.”
ANS: 4
Complementary therapies are those therapies used in addition to conventional treatment recommended by the person’s health care provider. They do not replace the prescribed treatment plan.
DIF: C REF: 775 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
20. A client diagnosed with hypertension and diabetes shares with the nurse that he has been using meditation to deal with the chronic pain he experiences from an old back injury. Which of the following questions shows the best understanding of the effects of meditation on the client’s systemic functions?
1.
“How many times a day do you meditate?”
2.
“Have you monitored your blood pressure lately?”
3.
“Have you had any improvement with your pain?”
4.
“Are you currently taking blood pressure medication?”
ANS: 4
Meditation may increase the effects of certain drugs. For example, monitor individuals taking antihypertensive medications or thyroid-regulating, antidepressant, or antianxiety medications. Prolonged practice of meditation techniques sometimes leads to the reduced need for certain medications such as antihypertensive medications. Whatever the case, monitor individuals learning meditation closely for physiological changes with respect to their medications. Adjustment of the medication is sometimes necessary. While the remaining options are not inappropriate, they do not assess the primary issue regarding medication.
DIF: C REF: 777 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
21. A nurse and client are engaged in imagery training. The nurse shows the best understanding of the importance of selecting an appropriate focus when stating:
1.
“Let’s discuss how to select today’s focus.”
2.
“Today’s focus will be auditory rather than visual.”
3.
“What do you find to be most effective as your focus?”
4.
“Review this list and select a focus for today’s session.”
ANS: 3
People typically respond to their environment according to the way they perceive it, as well as by their own visualizations and expectancies. Therefore individuals learn to regulate themselves by selecting appropriate visualizations and expectations. The remaining options do not allow the client to control the selection process.
DIF: C REF: 778 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
22. Acupuncture is contraindicated for which of the following clients?
1.
A 72-year-old asthmatic
2.
A 10-year-old hemophiliac
3.
A 23-year-old with Crohn’s disease
4.
A 40-year-old who is clinically depressed
ANS: 2
This treatment is contraindicated in persons who have bleeding disorders, thrombocytopenia, or skin infections or who have a fear of needles. The remaining options represent individuals who may experience benefit from the therapy.
DIF: C REF: 781 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
23. A client undergoing chemotherapy treatment for lung cancer drinks ginger tea to help manage the resulting nausea. Which of the following medications should the nurse review for interactions?
1.
Loop diuretics
2.
Anticoagulants
3.
Antidepressants
4.
Antihypertensives
ANS: 2
Ginger interacts with warfarin and other blood thinners, aspirin, and NSAIDs. The remaining options reflect interactions with chamomile, aloe, and licorice.
DIF: A REF: 782 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
24. Which of the following statements made by a nurse shows the most appropriate understanding of “skin hunger”?
1.
“For skin to be healthy, it must be fed.”
2.
“Being touched is as important as being fed.”
3.
“Touch provides emotional comfort to a client.”
4.
“Skin requires adequate nutrients and hydration.”
ANS: 1
Touch is a primal need, as necessary as food, growth, or shelter. Think of touch as a nutrient transmitted through the skin and “skin hunger” as a form of malnutrition that has reached epidemic proportions in the United States, especially among older adults. While the remaining options are not incorrect, they do not express the most appropriate appreciation for the need of human touch.
DIF: C REF: 779 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
25. Which of the following nursing statements best reflects the most therapeutic intervention regarding the client’s need for human touch?
1.
“I always ask my clients if they need a hug.”
2.
“It is important to use a light touch when giving a bath.”
3.
“I offer my clients a backrub whenever giving them bedtime care.”
4.
“When I meet a client for the first time, I always try to shake his or her hand.”
ANS: 3
Touch is a primal need, as necessary as food, growth, or shelter. This answer provides the most appropriate manner in which a nurse can provide touch from among the options.
DIF: C REF: 779 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
26. The nurse is discussing the importance of human touch with the family of a comatose client. The daughter states “I love my mother but I find it so hard to touch her when she’s like this.” Which of the following nursing statements reflects the most therapeutic response?
1.
“Maybe it will get easier each time you touch her.”
2.
“Touch is a human need, just like food, so please try.”
3.
“Do you think it would be more comfortable to try washing her face and hands?”
4.
“Your mother certainly wouldn’t want you to do something that you find so difficult.”
ANS: 3
Touch is a primal need, as necessary as food, growth, or shelter. This answer is the only option that attempted to provide an acceptable solution for the family member’s problem.
DIF: C REF: 779 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
27. A client diagnosed with osteoarthritis has been practicing tai chi regularly. Which of the following statements best shows the client’s understanding of the value of this complementary therapy?
1.
“It is a great way to socialize and exercise at the same time.”
2.
“I don’t like to exercise, but Tai Chi doesn’t seem like exercise.”
3.
“The moves are so beautiful, and I feel so graceful when I practice them.”
4.
“The gentle, slow movements exercise my joints without straining them.”
ANS: 4
Tai chi incorporates breathing; gentle, flowing movements; and meditation to cleanse, strengthen, and circulate vital life energy and blood. Therapy stimulates the immune system and maintains external and internal balance.
DIF: C REF: 773 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
28. A client is discussing his use of biofeedback. Which of the following client statements shows the best understanding of success?
1.
“I have set aside one hour a day for practice.”
2.
“My appointments are very important; I keep them all.”
3.
“I find it empowering that I can do something to help myself.”
4.
“Goals are important; setting them gives me something to work toward.”
ANS: 3
Clients who are compliant with appointments, practice times, and goal setting and basically take responsibility for their treatment tend to be the most successful since it provides a sense of control over the situation. The remaining options identify individual aspects of that control.
DIF: C REF: 779 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
29. A client recently experienced the loss of their significant other and has symptoms of distress. In selecting a complementary therapy, the nurse knows that the client may benefit the most from:
1.
Relaxation therapy
2.
Acupuncture
3.
Feldenkrais method
4.
Chiropractic medicine
ANS: 1
Relaxation techniques effectively reduces symptoms of distress in persons experiencing a variety of situations by giving them some control over their lives. An alternative method of producing analgesia. An alternative therapy based on body movements. An alternative therapy focused on restoring structural and functional imbalances.
DIF: A REF: 772 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Grief and Loss
30. In gathering information for the admission data base, the nurse discovers that a client who was admitted to the hospital for a total hip replacement has been taking ginkgo biloba to help with their memory. The nurse knows that this may cause an interaction with which of the medications that will likely be ordered for the client?
1.
Morphine sulfate
2.
Warfarin
3.
Docusate sodium
4.
Docusate sodium
ANS: 2
Increases the risk of bleeding.
DIF: A REF: 773 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies
31. An elderly client in a nursing home describes to the nurse that they are lonely. Based on this information, the nurse believes the patient may benefit from which of the following complementary therapies?
1.
Therapeutic Touch
2.
Chinese medicine
3.
Dance therapy
4.
Guided imagery
ANS: 1
Touch helps enhance self-esteem and sense of worth.
DIF: A REF: 775 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Behavioral Interventions
32. A client seeking care for stress tells the nurse that he is interested in seeking holistic care that incorporates body, mind, and spirit. The nurse knows that which of the following CAM therapies may be beneficial to him?
1.
Chiropractic medicine
2.
Chinese medicine
3.
European phytomedicine
4.
Allopathic medicine
ANS: 2
Includes many modalities including acupuncture, herbs, touch, moxibustion, and qigong. Physiotherapy by manipulation of spinal column. Herbal medicine. Traditional western medicine focusing on physical ailments.
DIF: A REF: 776 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Behavioral Interventions
33. Nurses who are interested in practicing CAM therapy can, with minimum preparation, incorporate which of the following into their nursing practice?
1.
Biofeedback
2.
Ayurveda
3.
Therapeutic Touch
4.
Acupressure
ANS: 3
Therapeutic Touch is the laying of hands on a client’s body. Biofeedback requires advanced preparation and the use of instruments. Ayurveda is a traditional Hindu system of medicine. Acupressure, a Chinese method of producing analgesia, requires advanced preparation.
DIF: A REF: 782 OBJ: Knowledge
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort
34. The nurse notes that the client’s blood pressure is substantially higher than it was on their last annual checkup. On questioning, the nurse learns that the client has been taking herbal therapy. The nurse understand that which of the following herbs is a central nervous stimulant that can cause a rise in blood pressure?
1.
Calamus
2.
Ginseng
3.
Feverfew
4.
Ephedra
ANS: 4
Ephedra is a central nervous stimulant.
DIF: A REF: 784 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse’s most informed response to a client’s question concerning what allopathic medicine (Western medicine) is least effective at dealing with should include: (Select all that apply.)
1.
Managing stress
2.
Disease prevention
3.
Treating chronic illness
4.
Meeting emotional needs
5.
Curing bacterial infection
6.
Treating acute emergencies
ANS: 1, 2, 3, 4
Allopathic medicine is effect in dealing with the management of bacterial infections and treating acute emergencies, while the remaining options represent conditions that are not as effectively managed.
DIF: A REF: 772 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
2. When discussing complementary medical therapies with a client, a nurse should include: (Select all that apply.)
1.
Herbalism
2.
Hypnotherapy
3.
Guided imagery
4.
Therapeutic touch
5.
Respiratory therapy
6.
Chiropractic therapy
ANS: 1, 2, 3, 4, 6
Complementary therapies include therapeutic touch, guided imagery and breath work, relaxation; exercise; massage; reflexology; prayer; biofeedback; hypnotherapy; creative therapies, including art, music, or dance therapy; meditation; chiropractic therapy; osteopathy; and herbalism. Respiratory therapy is not considered a complementary therapy.
DIF: A REF: 773 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
3. Which of the following objective assessment findings are likely to be seen in clients who have successfully implemented relaxation techniques? (Select all that apply.)
1.
Slower respirations
2.
Lower blood sugar levels
3.
Decreased heart rate
4.
Lower blood pressure
5.
Decreased deep reflexes
6.
Warmer skin temperature
ANS: 1, 3, 4, 6
Decreased heart and respiratory rates, decreased blood pressure and oxygen consumption, and increased alpha brain activity and peripheral skin temperature characterize the relaxation response. The remaining options are not typical characteristics of the relaxed state.
DIF: A REF: 783 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care & Comfort/Complementary and Alternative Therapies
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