EXAM 2 CHAPTER32 AND 27
A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? A)Complete bed bath B)Towel bath C)Tub bath D)Bed bath
ANSWER B............A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patient's energy.
Which action should the nurse be sure to take when preparing a patient for a bed bath? A)Wash the patient's body without assistance from the patient. B)Cover the patient with the top linens from the bed. C) Place the nurse call device within reach. D)Have the patient completely bathe himself to promote independence.
ANSWER C ....When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place prepackaged bathing product, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an "assist bath."
For which patient is it most important to provide frequent perineal care? The patient: A) Who has had an episode of diabetic ketoacidosis B) Who has a circumcised penis C)With a history of acute asthma D)With active lower gastrointestinal bleeding
ANSWER D The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.
The nurse is checking the gastric aspirate for the patient receiving tube feedings. She notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3. Which action should she take? A) Hold the tube feeding for 2 hours; continue if residual is less than 200 mL. B) Flush tube with 30 mL of sterile water; resume tube feeding at prescribed rate. C) Administer a promotility agent as prescribed; resume feeding in 1 hour. D) Stop the feeding immediately; then notify the prescribing provider.
ANSWER ID D .......Normal gastric fluid should be clear, green, and acidic (pH 5.0). If the gastric aspirate is pale yellow and cloudy with a pH of 7.3 (alkaline), the nurse must stop the tube feeding immediately and notify the prescriber of the feedings. This finding might indicate the feeding tube has migrated to the lungs, which could lead to aspiration pneumonia and become a medical emergency. Holding the feeding for 2 hours and continuing after that could lead to aspiration pneumonia because the quality of the fluid indicates the placement of the tube is in the lungs. Flushing the tube and resuming feedings when the feeding tube is in the lungs could lead to a medical emergency. A promotility agent (e.g., metoclopramide) would be given if the patient has gastric residual volume (GRV) of 250 mL or more for two consecutive checks. However, if the GVR is more than 500 mL, the nurse would stop the feeding and reassess the patient.
A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? A) Passive ROM B) Turning the patient every 2 hours C) Active ROM D) Administering glucosamine supplements
ANSWER IS A .....Passive ROM involves moving the joints through their ROM when the patient is unable to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive scientific evidence regarding the benefit of this substance to improve joint function.
A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? A)Superficial layers of skin were absent. B)Epidermal layer of skin was rubbed away. C) Lesion caused by tissue compression was present. D) Skin was softened from prolonged exposure to moisture.
ANSWER IS A.....Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or shearing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.
A teenage boy was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, "Our son is just staring off into space; he won't talk to us. We are worried because he has not even listened to his iPod, watched television, or played his video games for 2 days. That is so unlike him." What is the best response the nurse can make? A) "I will inform his doctor and see whether we can get your son started on an antidepressant medication." B) "Your son had a major injury, and his immobility might be causing him to feel isolated and depressed." C) "He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse." D) "He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to do."
ANSWER IS B .......Being immobile, whether in the hospital or home, leads to isolation and mood changes. Patients who are in bed for long periods can suffer from psychological changes such as depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities.
A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis? A) Glycogen B) Ketones C) Insulin D) Proteins
ANSWER IS B .......When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis. Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be used for fuel as long as fats were available.
The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, "I feel so light-headed and weak," as her knees begin to buckle. The nurse's best action at this time would be to: A) Grab her under the arms and hold her up as he calls for assistance B) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall C) Assist the patient to slide down his leg as he guides her to a seated or lying position D) Instruct the patient to grab the rail in the hallway while he calls for assistance
ANSWER IS C
While the nurse is performing a nutritional assessment her patient states, "I am on a vegan diet. I have been a vegan for 10 years. What do think?" What is the best response by the nurse? A) "I think it is your right to be on whatever diet you would like to be on." B) "It is fine; however, you may not be getting all the nutrients you need." C) "Can you tell me about the foods you eat along with any other supplements you take?" D) "Is this a religious or cultural requirement for you?"
ANSWER IS C
An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and become frail. Her appetite and activity level are reduced and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be? A) Distaste for the food served B) Need for teaching about nutrition C) Anxiety D) Adult failure to thrive
ANSWER IS D .....Adult failure to thrive is a complex disorder seen in many institutionalized older adults. It is characterized by weight loss, decreased activity and interactions, and increasing frailty. The overall description presented by the nurse is consistent with adult failure to thrive. The resident's poor appetite is not a result of not understanding nutrition or the need to eat. Teaching would not be helpful in this instance. In this situation, the resident's poor appetite is more likely related to depression and social withdrawal or even dementia than to anxiety. Most skilled nursing facilities could individualize the dietary selection to some degree to provide residents with adequate nutrition.
A patient has started a fitness program. What program features illustrate that he has started a well-rounded program? Select all that apply. A)Balance exercises B)Flexibility C)Resistance training D) Aerobic conditioning
ANSWER IS A,B,C,D
When making an occupied bed, which of the following is most important for the nurse to do? A)Keep the siderail raised on both sides of the bed. B)Keep the bed in the low position. C)Move back and forth between the sides of the bed when adjusting linens. D) Use a bath blanket or sheet to maintain patient warmth and privacy.
ANSWER IS D
Melan(o) means: Red Blue Black Yellow
BLACK
Lact(o) means: cloudy has odor eyes Milk
MILK
Question 60 1 / 1 pts Ortho means: supine position straight position upright position prone position
STARIGHT POSITIIN
Gluc(o) means: Sour Sweet Salt Serum
SWEET
For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply. A) Keep the head of the bed elevated for 30 to 45 minutes after feeding. B)Provide a full liquid diet that is easy to swallow. C)Remind the patient to raise the chin slightly to prepare for swallowing. D)Check inside the mouth for pocketing of food after eating.
A D
To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) is an incomplete protein that should be consumed with a complementary protein? Select all that apply. A) Whole grain rice B)Lentils C) Soybeans D)Egg whites E) Quinoa
A, B
Select the factors known to affect sleep. Choose all that apply. A) Environment B)Lifestyle C)Ethnicity D) State of health E)Age
A,B,D,E
During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate? A) Increases the rate by 7% B) Decreases the rate by 14% C) Increases the rate by 35% D) Decreases the rate by 28%
ANSWER IS C .......Basal metabolic rate increases 7% for each degree Fahrenheit (0.56°C); therefore, this patient's temperature rise is an increase of 35%.
Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Select all that apply. A)Keep objects close to your body when carrying them. B)Use a wide base of support with your feet at shoulder width. C)Bend at the waist to lift heavy objects from the floor. D)Stand with the body in alignment and erect posture.
ANSWER A , B, D
The nurse is instructing a patient about the need to replace fluid before, during, and after exercise to avoid dehydration. On what basis should she teach the patient to determine the amount of fluid to consume? Select all that apply. A) Duration of exercise B) Level of fitness C) Degree of thirst D) Environmental temperature
ANSWER A,D Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of fitness. During intense exercise, the body can lose 2 liters of fluid for every hour of exercise. Elevated environmental temperatures also increase the amount of fluid lost through sweating. When athletes drink according to thirst, the risk of overdrinking and so developing exercise-associated hyponatremia is minimized (Noakes, 2007). Conversely, exercise can suppress thirst, making it an unreliable signal to replace fluids lost with exercise.
The nurse planning the care of a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patient's integument? A) Offering the patient six small meals a day B) Assisting the patient to sit in a chair three times a day C) Turning the patient at least every 2 hours D) Administering fluid boluses as directed by the healthcare provider
ANSWER IS C .......External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure.
A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse? A) "It depends on what you mean by high blood sugar. You will need to obtain more information from your provider as diabetes is a very complicated disease process." B) "I will be able to explain this to you a little better later when we talk about diabetes. For now, I have to finish my assessment and then we can get back to your question." C) "I will teach you how to perform glucose testing when I finish your assessment. As long as your blood sugar remains somewhere in the 120 to 140 range, you will be doing well." D) "I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells will allow only a limited amount to enter. The cells can't use the excess glucose."
ANSWER IS D
Which nutrient deficiency increases the risk for pressure ulcers? A) Fat B) Vitamin K C) Carbohydrate D) Protein
ANSWER IS D
The nurse planning care for a patient after severe head trauma and long-term unresponsiveness considers which effect of immobility affecting the lungs? Select all that apply. a) Hypocarbia B) Pooled secretions C) Reactive airway D) Hyperventilation E) Atelectasis
B , E
Pseudo means: Negative False Incorrect Accurate
FALSE
Lip(o) means: mouth sugar Fat protein
FAT
Adip(o) means: back Hot proteins Fats
FATS
The nurse assessing the mobility of a patient with Parkinson's disease might expect to observe which type of gait? a) Steppage b) Scissors c) Propulsive d) Antalgic
answer is c .......A propulsive gait is characterized by a stooped, rigid posture with the head and neck bent forward. The patient takes small, shuffling steps in involuntary acceleration, which is typical of a parkinsonian gait. An antalgic gait is a limp to avoid pain when bearing weight on an injured lower extremity. In a scissors gait, the legs flex slightly at the hip and knees; the thighs cross in a scissor-like motion, common with cerebral palsy, stroke, head trauma, or brain tumor. A steppage gait is an exaggerated lifting of the leg that appears as though the foot is floppy and toes point downward. This occurs with Guillain-Barré syndrome.
Erythr(o) means: Blue white red yellow
RED
While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest? a) Normal aging process b) Inadequate dietary intake c) Fungal infection d) Excessive use of silver salts
answer is b
A patient is on strict bedrest for 5 days. During this time, she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is Constipation related to: a) Change in environment b) Change in previous pattern c) Immobility d) Dietary intake
answer is c
A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: a) Caffeine intake. b) Increased exercise. c) Nicotine withdrawal. d) Environmental changes.
answer is c
What action is most important in limiting the nurse's risk of back injuries? a) Use good body mechanics at all times. b) Work with another nurse or an aide when lifting and turning patients. c) Avoid manual lifting by using assistive devices as often as possible. d) Develop a lift team at the clinical site.
answer is c .........Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the ANA Handle With Care program advocates the regular use of assistive devices as well as avoiding manual lifting.
euk(o) OR leuc(o) means: white yellow Red Blue
WHITE
Cirrh(o) means: Pink Red Blue Yellow
YELLOW
Which of the following is/are a benefit of bathing? Select all that apply. A)Increases depth of respirations B)Constricts blood vessels c)Provides opportunity for assessments d)Reduces sensory input
answer A , C
Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. a)Palms b)Buccal mucosa c)Around the lips d) Tongue
answer a,b,d ........ In dark-skinned people, cyanosis can be best assessed by examining the palms of the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be used.
A person who is deprived of REM sleep for several nights in succession will usually experience: a) REM rebound. b) Extended NREM sleep. c) Insomnia. d) Paradoxical sleep.
answer is a
The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply. A) Bruxism B)Snoring C) Daytime fatigue D) Enuresis E) Drooling
ANSWER IS B,C
When making rounds on the night shift, the nurse observes her patient to be in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient most likely experiencing? a) REM b) NREM III c) NREM II d) NREM I
answer is b
Which of the following factors has the greatest positive effect on sleep quality? a) Sleeping in a quiet environment b) Sleeping hours in synchrony with the person's circadian rhythm c) Spending additional time in stage III of the sleep cycle d) Napping frequently during the day hours
answer is b
Which patient teaching would be most therapeutic for someone with sleep disturbance? a) Give yourself at least 60 minutes to fall asleep. b) Do not go to bed feeling upset about a conflict. c) Catch up on sleep by napping or sleeping in when possible. d) Avoid eating carbohydrates before going to sleep.
answer is b
Question 54 2 / 2 pts While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication? A) Kidney failure B) Lung cancer C) Stroke D) Liver failure
ANSWER IS C
Which of the following patients would you expect to be at risk for decreased activity? Select all that apply.A(Someone living in a skilled nursing facility B)Healthy adult who works as a computer programmer C)Older adult who walks at the mall for physical activity D) Obese child who enjoys video games
A,C,D
The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? A)Rub briskly when towel drying. B)Use cool water for bathing. c)Provide care in short intervals. d)Avoid bathing the patient.
answer is c ......The nurse should provide care in short intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.
When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? a) Avoid strenuous activity that puts stress on the bones. b) Schedule regular healthcare checkups. c) Start a weight-bearing exercise program. d) Take a calcium supplement twice a day.
answer is c .....Osteoporosis causes bones to become porous and weak. Starting a weight-bearing exercise program is the most important aid in promoting bone strength and decreasing the rate of bone loss. Calcium supplementation does help maintain bone density.
Which instructions should the nurse give to the patient complaining of constipation? Select all that apply. A)Drink at least eight glasses of water or fluid per day. B)Gradually increase your fiber intake to 25 grams per day. C)Include a minimum of four servings of meat per day. D) Exercise at least 60 minutes per day as you feel necessary. E)Use the restroom when you feel the urge to defecate.
A,B,E
For which patient(s) should the nurse avoid using back massage? Select all that apply. a)One who sustained a leg fracture in a sledding accident b) One who underwent heart surgery 3 days ago C)One who sustained rib fractures from a fall D)One who underwent a lumbar laminectomy
ANSWER B,C..... Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or leg fracture.
The nurse assigned to an oncology unit reports that three of the patients with cancer do not have an appetite and have eaten little during the shift. What strategies can the nurse on the next shift use to increase her patients' appetites? Select all that apply. A)Keep the patients' rooms neat and clean. B)Offer frequent, smaller meals. C)Provide or assist with frequent oral hygiene. D)Serve foods with little aroma. E) Increase liquid intake with meals.
A,B C
A nurse on a medical-surgical unit asks a licensed practical nurse (LPN) to help with nutritional assessments for newly admitted patients. What part of the nutritional assessment can be delegated to the LPN? Select all that apply. A)Height and weight B)Intake and output C)Nutritional history D)Interpreting laboratory findings E)Body fat measurement
A,B, C
The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? a) "Bathe the patient from head to toe, cleanest areas first." b) "Provide the patient with warm water for washing his perineum." c) "Cleanse only those areas likely to cause odor." d) "Wash the patient's back, buttocks, and perineum first."
answer is a
The primary focus of your interventions for a 6-year-old child who sleepwalks would be to: a) Maintain patient safety during episodes of somnambulation. b) Provide a quiet environment for nighttime sleep. c) Administer and teach about medications to suppress stage III sleep. d) Encourage the child to verbalize feelings regarding sleep pattern.
answer is a
Which of the following is the main difference between sleep and rest? a) Sleep is characterized by an altered level of consciousness. b) Short periods of sleep do not restore the body as much as do short periods of rest. c) In sleep, the body may respond to external stimuli. d) The metabolism slows less during sleep than during rest.
answer is a .......During rest, the mind remains active and conscious; sleep is characterized by altered consciousness. Sleep is a cyclic state of decreased motor activity and perception. A sleeping person is unaware of the environment and does respond selectively to certain external stimuli. However, at rest, the body is disturbed by all external stimuli; sleep restores the body more than does rest. The metabolism decreases more during sleep than during rest.
Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? a) 105°F (40.6°C) b) 99°F (37.2°C) c) 103°F (39.4°C) d) 102°F (38.9°C)
answer is a ......Bath water temperature should be 105°F (40.6°C) to prevent chilling, burning, and excess drying of the skin.
rom what stage of sleep are people typically most difficult to arouse? a) REM b) NREM, sleep spindles c) NREM, alpha waves d) NREM, delta waves
answer is d ......Stage III of NREM (delta wave) is the deepest stage of sleep—not REM. It is difficult to awaken someone in stage III slow wave NREM sleep, and if she is awakened, the person may appear confused and react slowly. Stage I NREM is a light sleep from which the sleeper can easily be awakened. Stage II (sleep spindles) is also light sleep; the sleeper in this stage is easily roused. REM sleep is the stage at which most dream activity occurs, as well as more spontaneous awakenings.
A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately 3 to 4 times per week. The nurse's best response would be which of the following? Choose all that apply. A)"Wake your daughter every 4 hours to use the bathroom." B)"Try a bed alarm to wake her when she starts wetting the bed at night." C) "You might consider purchasing protective pads for the bed." D) "Your daughter's bladder is still developing at this point in her life." E) "Be patient; most children outgrow enuresis."
ANSWER C, E ... Enuresis is nighttime incontinence past the stage at which toilet training has been well established. Most incidents occur during NREM sleep when the child is difficult to arouse. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. A bed alarm can be used for older children (typically older than age 10 or 12) who are resistant to other
For an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements? A) Serum albumin of 3.2 g/dL B) Serum glucose of 78 mg/dL C) Creatinine of 1.0 mg/dL D) Potassium of 4.1 g/dL
ANSWER IS A
A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? A) Thrombophlebitis B) Pneumothorax C) Hypoglycemia D) Sepsis
ANSWER IS C
A frail, elderly man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight bearing on his left lower leg. What is the best intervention to help him use his walker? A) Isometric toning of lower legs B) Aerobic exercise with deep breathing C) Arm resistance training D) Quadriceps and gluteal repetitions
ANSWER IS C .......Arm strength is necessary for ambulating with a walker and other assistive devices. Upper body resistance training increases muscle strength and tone, which will aid him in using the walker more easily. Toning the lower body through exercise of the quadriceps and gluteal muscles, although important for regaining strength in general after surgery, does not specifically aid in using a walker. Aerobic exercise with deep breathing produces the greatest benefit to the cardiovascular health and does little to improve the upper body strength needed for ambulating with an assistive device.
The nurse attempts to transfer a totally dependent patient from a stretcher to a bed. What is the best step to reduce the musculoskeletal risk factors? A) Use a wide base of support when transferring. B) Use a mechanical lift to transfer the patient. C) Ask a coworker to help transfer the patient unaided. D) Use transfer roller sheet when transferring.
ANSWER IS D
The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will: a) Limit exercise to 1 hour per day early in the day. b) Consume only one caffeinated beverage per day. c) Verbalize that she is sleeping better and feels less fatigued. d) Demonstrate effective guided imagery to aid relaxation.
answer is c .....The patient would verbalize that she is sleeping better and feels less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem. The other options are outcomes that demonstrate only that the patient took certain actions. They would not, if achieved, demonstrate that the problem of Disturbed Sleep Pattern had been resolved.
For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. a) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion b) 32-year-old admitted with a closed head injury c)62-year-old who underwent surgical repair of a bowel obstruction 2 days ago d) 76-year-old admitted with septic shock
answer is c.........Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical-thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical-thinking skills of a registered nurse to detect respiratory compromise quickly.
During which of the following developmental stages does a person tend to need the most hours of sleep? a) Older adulthood b) Adolescence c) Middle adulthood d) Toddler
answer is d .....Toddlers (ages 1 to 3 years) require 12 to 14 hours of sleep in a 24-hour period. Adolescents (ages 12 to 18 years) usually need 8 to 9 hours in a 24-hour period. Middle-aged adults (ages 40 to 65 years) typically require 7 hours in a 24-hour period. Older adults (age 65 years and older) often need 5 to 7 hours of sleep in a 24-hour period.
