first semester NCLEX review
A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?
"According to HIPAA legislation, you have a right to request changes to inaccurate information."
Which question, used for a pain assessment, would assess a client for the perception of pain?
"Do you find any meaning in your pain?"
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?
"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."
A nurse who usually works on the surgical unit is asked to float to the oncology unit because of staffing needs. Which statement by the nurse indicates the possibility of the nurse experiencing culture shock?
"I am very stressed now because I do not understand how things work on this unit."
burnout
(1) cumulative state of frustration with the work environment that develops over a long time; (2) behaviors exhibited as the result of prolonged occupational stress
Crisis
(1) point at which body temperature drops rapidly to normal; (2) occurs when coping and defense mechanisms are no longer effective, resulting in high levels of anxiety, disorganized behavior, and the inability to function normally
The guide (stress) includes taking steps to
(a) identify the stressor, (b) identify your personal feelings regarding the stressor, (c) decide if you want to change the situation causing the stress, (d) consider whether you can change the dynamics of the situation, (e) identify the plan of action, (f) involve key outside parties (as needed), (g) take action, and (h) evaluate the outcomes
The nurse explains to another nurse the meaning of situational awareness. Which client exemplar does the nurse use to illustrate situational awareness?
"If the call bell has been out of the client's reach, I ask if the client needs to void or defecate."
A new client comes to the primary care clinic and asks for help treating head lice. The interview reveals that the client lives with nine other people in a one-bedroom apartment. Which statement by the client is nurse's priority concern?
"We do not have running water."
If I have to touch it, or ask the patient to verify edema its likely
1+ or trace edema
Adults respirations breaths/min
12 to 20
If its becoming pitting edema its likely
3+
The peak elevation of a person's temperature occurs between
4 and 8 PM.
Adult pulse beats/min
60 to 100 bpm
The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?
Activate the fire alarm and notify the appropriate person.
The nurse comes into the room and observes Edith Jacobson moaning and guarding her leg. What should the nurse do next?
Administer pain medication.
When performing hand hygiene, when is it necessary to use soap and water instead of an alcohol-based hand rub?
After using the bathroom
Hyperventilation
Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood increases the rate and depth of respirations; Increased rate and depth
Which of the following nursing process components is comprised of collecting data about the patient?
Assessment
Korotkoff Sounds Phase 3
Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
The telemetry nurse is conducting an initial cardiac assessment on a client admitted with chest pain and coronary artery disease (CAD). What should the nurse do first?
Examine the client's chest for any visible pulsations
The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.
Explain rationale for use to the client and family. Pad bony prominences. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. Ensure that two fingers fit between the restraint and the client's skin. Position limbs in normal anatomic position. Secure restraints to the bed frame with quick-release knots.
True or false: Phase II Korotkoff sounds are characterized by distinct, abrupt, and muffling sounds with a soft, blowing quality.
False
The nurse, assessing a client for pain, looks for behavioral responses to the pain. Which is an example of a behavioral response?
Grimacing
Which of the following abnormalities is most likely seen in patients experiencing a panic episode? Seizure, Hallucination, Autonomic neuropathy, Avolition, Anhidrosis, Trichotillomania,
Hallucination
Panic
Hallucination, inability to function or communicate. manifested by difficulty communicating verbally, agitation, trembling, poor motor control, sensory changes, sweating, tachycardia, hyperventilation, dyspnea, palpitations, a choking sensation, and sensations of chest pain or pressure.
Which of the following clinical features is most likely to be seen in patients with mild anxiety? Cool, clammy skin, Heighten perception, Automatic behavior, Hyperventilation, Headache, Apraxia,
Heighten perception
Antiembolism stockings often have an inspection window. Which statement by the nurse indicates understanding of the purpose of the inspection window?
I will place the inspection window on top of the foot so I can easily assess capillary refill, temperature, and pulses of the patient's feet.
Types of Fever
Intermittent, Remittent, Sustained or Continuous, and relapsing or recurrent
An example of a disease often diagnosed in a specific population is Tay--Sachs disease, which is associated with individuals of Eastern European _____________ descent.
Jewish
Various studies suggest that a sleep-weight link is possibly related to two hormones: ________, which signals the brain to stop eating, and ghrelin, which promotes continued eating.
Leptin
neural centers for blood pressure regulation
Located in the brain in an area called the cardiovascular center
Which of the following is most likely a clinical feature of obstructive sleep apnea? Hyperventilation, Ptosis, Loud snoring, Kussmaul respirations
Loud snoring
What action would the nurse perform when removing a bedpan following client use?
Lower the head of the bed slightly
Which nursing interventions should a nurse anticipate for an older patient with a hip fracture? (Select all that apply.)
Maintain non-weight bearing status., Prevent skin breakdown by frequent repositioning., Use logrolling techniques to turn the patient in bed., Reassess the affected extremity.
Which nursing activity reflects secondary prevention?
Making a referral for a mammogram
A client rates pain on a numeric pain scale at a "5" out of 10. What type of pain is this client experiencing?
Moderate
Edith Jacobson has been taking raloxifene for her osteoporosis. What is the priority nursing consideration for raloxifene related to the patient's current hip fracture?
Monitor for blood clot formation.
cranial nerve 3
Oculomotor nerve (eye movement)
Which of the following clinical features is most likely to be seen in patients with moderate anxiety? Daytime sleepiness, Photosensitivity, Perception narrowed, Somnolence, Psychoticism, Photophobia,
Perception narrowed
The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?
Perform a circulation check and offer toileting and hydration.
What is the final step in removing personal protective equipment (PPE) when caring for a patient requiring droplet precautions?
Perform hand hygiene
Which is is the priority activity for the nurse to perform in the implementation step of the nursing process?
Reassess client's needs.
Which of the following is a lifestyle modification that may be recommended to patients with hypertension? ECG monitor, avoid caffeine, carry inhaler, increase sleep, cardiac stress test, relaxation techniques
Relaxation Techniques
Which of the following is most likely an intervention associated with the treatment of a fever? Monitor for hypothermia, NPO, Limit fluid intake, Warm Blankers, Provide hot towels on forehead, Remove excess clothing and blankets
Remove excess clothing and blankets
When considering hand hygiene, which action will best remove a possible microorganism reservoir?
Removing any rings
A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority?
Rescue the client.
A bedridden hospitalized client expresses a belief that missing weekly church service is a failure to live by the church's rules. The notes not missing a service in the past 50 years. Which is an appropriate nursing diagnosis for this client?
Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt
Which of the following is most likely a clinical feature of obstructive sleep apnea? Crescendo-decrescendo murmur, Attenuation reflex, Startle response, Hering-breuer reflex
Startle response
performed as the first part of a situational assessment
The ABC, respiratory, and tubes
Conduction
The transfer of heat to another object during direct contact
Which of the following is most important when planning goals for a patient in the nursing process? Timed, High mortality rate, Open-ended, Close observation
Timed
true or false Terminal weaning is the gradual withdrawal of mechanical ventilation from a patient with a terminal illness or an irreversible condition with a poor prognosis.
True
Biot's respirations
Varying depth and rate of breathing, followed by periods of apnea; irregular
cranial nerve 6
abducens nerve
apnea
absence of breathing
cranial nerve 11
accessory nerve
Dysrhythmia
an abnormal cardiac rhythm
general adaptation syndrome (GAS):
biochemical model of stress describing the body's general response to stress; physiologic response to stress
hypothermia blanket, or cooling pad
blanket-sized aquathermia pad that conducts a cooled solution, usually distilled water, through coils in a plastic blanket or pad.
Hypotension
blood pressure below the lower limit of normal; blood pressure that is lower than 90/60 mm Hg
According to Kübler-Ross, in the _____________ stage of dying, the patient goes through a period of grief before death.
depression
beneficial effects of fever
destruction of disease-causing microorganisms, increased susceptibility of disease-causing microorganisms to anti-infective agents, and enhanced response by the immune system
pulse pressure:
difference between systolic and diastolic pressures
Dyspnea
difficult or labored breathing
Fever of unknown origin
fever of 38.3°C (101°F) or higher that lasts for 3 weeks or longer without an identified cause
crisis intervention
five-step problem-solving technique to promote adaptation and improve future coping
Brawny edema
fluid that can no longer be displaced secondary to excessive interstitial fluid accumulation and is without pitting.
During your assessment of a patient with a fever, which of the following is most likely to be seen? flushed skin, warm to touch, abnormal breath sounds, hypoglycemia, flushed skin, cool to the touch, fiery red mucosa, calabar swellings in skin
flushed skin, warm to touch
Which of the following substances is primarily absorbed in the proximal jejunum and duodenum? folate, cobalamin (Vitamin B12), ergocalciferol (Vitamin D2), vitamin A, alcohol, thiamine (Vitamin B1)
folate
blood pressure
force of blood against arterial walls
defense mechanisms:
forms of self-deception; unconscious process the self uses to protect itself from anxiety or threats to self-esteem
Respirations
gas exchange between the atmospheric air in the alveoli and blood in the capillaries
Adaptation to acute and chronic illness or to traumatic injury involves two sets of adaptive tasks:
general tasks and illness-related task
Ability to taste is the sensory function of the
glossopharyngeal nerve
cranial nerve 9
glossopharyngeal nerve
Hyperthermia
high body temperature
Pericardial friction rub
high pitched, scratchy sound usually found with an inflamed pericardium
The diaphragm of the stethoscope is useful for hearing
high-frequency sounds, such as respiratory sounds, because it screens out low-frequency sounds.
systolic pressure
highest point of pressure on arterial walls when the ventricles contract
Prone position is used to assess
hips and posterior thorax
cranial nerve 12
hypoglossal nerve (tongue movement)
Circadian rhythm synchronization exists when a person's sleep-wake patterns follow the body's inner biologic clock located in the __________ (part of the brain).
hypothalamus
The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?
identifies client's full name and date of birth
Gender __________ is the inner sense a person has of being male or female, which may be the same as or different from the person's biological sex.
identity
Adventitious crises
include accidental and unexpected events resulting in multiple losses, and major environmental changes—such as fires, earthquakes, and floods—that involve not only individuals but also entire communities.
The body mass _______ , a reliable indicator of total body fat stores, is a ratio of weight (kilograms) to height (meters).
index
Which of the following is the most important characteristic regarding the planning component of the nursing process? 3 forms, observation, individualized to patient, no pain
individualized to patient
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
intervention
Which of the following substances is primarily absorbed in the duodenum? magnesium, cobalamin (Vitamin B12), Iron, Water, Alcohol, Bile
iron
Who is responsible for obtaining Informed Consent?
the provider who will perform the procedure
diuretics
to decrease fluid volume
cranial nerve 5
trigeminal nerve
anxiety
vague sense of impending doom or apprehension precipitated by new and unknown experiences
Presence of a gag reflex is tested in motor function of the
vagus nerve
cranial nerve 10
vagus nerve
Homeostasis
various physiologic and psychological mechanisms respond to changes in the internal and external environment to maintain a balanced state
cranial nerve 8
vestibulocochlear nerve
Which of the following substances is primarily absorbed in the terminal ileum? vitamin B12, folate, biotin, vitamin B1, Iron, Vitamin B2
vitamin B12,
Pulse
wave produced in the wall of an artery with each beat of the heart
Which of the following is a lifestyle modification that is commonly recommended to patients with hypertension? limit protein in diet, lifelong hormone therapy, carry inhaler, weight reduction and exercise, high sodium diet, avoid caffeine
weight reduction and exercise,
The nurse is aware that nursing diagnoses are:
within the nursing scope of practice to develop and client-focused.
A provider orders docusate sodium 100 mg, PO twice a day for an older patient. The pharmacy provides docusate sodium liquid 150 mg/15 mL. How much medication should the nurse administer?
10mL
Adult blood pressure mm Hg
120/80
A diagnosis of hypertension is made when the systolic pressure is _______ mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
140
the patient's elbows should bet at _______ degree angle while the hands are gripping the walker
15 to 30
If I can see it without touching it its likely
2+
A nurse is conducting a peripheral vascular assessment on a client admitted with congestive heart failure. The nurse notes an 8-mm deep depression in the skin after pressing that remains for a prolonged period on both legs. How should the nurse document this finding?
4+ pitting edema
the risk for diabetes and cardiovascular disease increases with a waist circumference measurement of 35 inches or more for women and _____ inches or more for men.
40
3+ pitting edema
6-mm deep depression that lasts a few seconds.
Which statement best defines a human infection?
A disease state that is a result of pathogens in or on the body
The situational assessment includes:
ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored.
Which one of the following acronyms/mnemonics is most closely associated with the nursing process?
ADPIE
The nurse is to assess the cranial nerves of a client admitted with a suspected tumor of the sternocleidomastoid muscle. When assessing the motor function of the spinal accessory nerve, what is the nurse evaluating?
Ability to rotate the head
The process of cultural assimilation or ___________________ occurs when a minority group, living within a dominant group, takes on the values of the dominant culture.
Acculturation
Emotional symptoms of prolonged stress
Alcoholism and drug abuse, depression, suicide, accidents, and eating disorders have also been associated with chronic stress
Cheyne-Stokes respirations
Alternating periods of deep, rapid breathing followed by periods of apnea; regular
The nurse is performing a quick assessment at the beginning of the shift. During auscultation of the client's lungs, decreased breath sounds, prolonged expiration, and expiratory wheezes bilaterally are auscultated. What would the nurse suspect?
An acute asthmatic exacerbation is occurring
A client tells the nurse that the heartburn she is experiencing is worse when she eats spicy foods. What would the spicy food be considered?
An aggravating factor
During _____________ loss, a person displays loss and grief behaviors for a loss that has yet to take place.
Anticipatory
The most common response to stress is _________, a vague, uneasy feeling of discomfort or dread from an often unknown source.
Anxiety
What would be a priority nursing diagnosis for Edith Jacobson related to her psychosocial needs?
Anxiety
Which of the following is most likely a clinical feature of obstructive sleep apnea? Hypotension and tachycardia, Hyperventilation, Apnea, Metabolic acidosis
Apnea
A client with a history of congestive heart failure comes to the cardiac wellness clinic reporting "frequent awakening from sleep due to shortness of breath." Which action by the nurse is most appropriate?
Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
The nurse is conducting a neurovascular assessment on a postoperative patient who experienced a total knee arthroplasty (TKA). What is the nurse's initial intervention when it appears that there is an absence of a pulse in the affected foot?
Assess the capillary refill in both longer extremities
The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate?
Assess the client's beliefs about family support during hospitalization.
The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?
Assess the client's need for fluids and toileting every 2 hours.
A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?
Assessment
Which nursing activity reflects care given on the tertiary level of healthcare delivery?
Assisting with transplant surgery
The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. What characteristic of the pain is the nurse assessing with this question?
Associated phenomena
Which nursing action can be categorized as a surveillance or monitoring intervention?
Auscultating of bilateral lung sounds
The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?
Auscultation of short, high-pitched popping sounds during inspiration
Which of the following findings is most likely to be seen in patients with severe anxiety? Aphasia, Psychoticism, Automatic behavior, Apraxia, Photosensitivity, Trichotillomania
Automatic behavior
The pulse is regulated by the _____________ nervous system through the sinoatrial (SA) node, the pacemaker of the heart.
Autonomic
Physiologic indicators of prolonged stress
Backache or stiff neck Chest pain Constipation or diarrhea Decreased sex drive Dilated pupils Dry mouth Headache Increased urination Increased perspiration Increased pulse, blood pressure, and respirations Nausea Sleep disturbances Weight gain or loss
A stress management technique known as _____________ is a method of gaining mental control of the autonomic nervous system, which regulates body responses such as blood pressure, heart rate, and headaches.
Biofeedback
Culture conflict occurs when people become aware of cultural differences; cultural ____________ occurs when one ignores differences and proceeds as though they do not exist.
Blindness
Crackles
Bubbling, crackling popping Low-to high-pitched, discontinuous sounds Auscultated during inspiration and expiration Opening of deflated small airways and alveoli; air passing through fluid in the airways Louder in inspiration
The nurse is assessing the pain of a neonate with altered respirations. Which pain assessment scale would be the best choice for this client?
CRIES pain scale.
The nurse is to assess the cranial nerves of a client admitted with a recent cerebral vascular accident. What is the nurse evaluating when assessing the motor function of the glossopharyngeal nerve?
Capability to swallow.
During your assessment of a patient with a fever, which of the following is most likely to be seen? Euphoria, Change in LOC, Congestion, Tinnitus, Polyphagia, increased appetite
Change in LOC
In order for a communication process to occur, three components are needed: a source or sender, the message, and the __________, the medium the sender selects to send the message.
Channel
Korotkoff Sounds Phase 4
Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure
Korotkoff Sounds Phase 2
Characterized by muffled or swishing sounds; these sounds may temporarily disappear, especially in hypertensive people;
Korotkoff Sounds Phase 1
Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure
The nurse is caring for a client who asks to use a bedside commode. Prior to assisting the client, what things are important for the nurse to assess? (SATA)
Check for the presence of drains and IV fluid lines., Evaluate the client for any functional limitations., Assess client for weakness or unsteady gait.
The nurse is preparing a bedpan to use for a client post-abdominal surgery. What is the most important concept that the nurse should remember when assisting a client with a bedpan?
Client dignity
Commonly Occuring Defence Mechanisms
Compensation, Denial, displacement, dissociation, Introjection, projection, rationalization, reaction formation, regression, repression, sublimation, undoing
The mechanics of heat transfer, known as _____________, refers to the transfer of heat to another object during direct contact.
Conduction
Which of the following is the most appropriate intervention used in the management of obstructive sleep apnea? Gentle stimulation, Continuous positive airway pressure (CPAP), Cryotherapy, Mannitol (Osmitrol),
Continuous positive airway pressure (CPAP)
The gerontologic nurse is assessing the muscles of an older adult client. Which muscle components are the most important for the nurse to assess with this client?
Contour, pain, range of motion, and symmetry, Tone, strength, size, and tenderness
An anti-inflammatory hormone released by the adrenals, known as ________, regulates the inflammatory response.
Cortisol
apical-radial pulse rate
Counting of the pulse at the apex of the heart and at the radial artery simultaneously
The emergency room nurse is caring for a client reporting dizziness and headache with identified nystagmus. Which cranial nerves would the nurse plan to assess?
Cranial nerve 3, Cranial nerve 4, Cranial nerve 5
The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?
Create an addendum with a correction.
Typical coping behaviors include the following:
Crying, laughing, sleeping, cursing Physical activity, exercise Smoking, drinking Lack of eye contact, withdrawal Limiting relationships to those with similar values and interests
Accepting cultural differences in the assessment of health care needs is an example of __________ competent nursing care.
Culturally
Which term is most appropriate for describing a healthcare practitioner who is respectful of the healthcare traditions of other cultures?
Culturally sensitive
Which intervention ordered for Mr. Griffin poses the greatest risk for injury?
Daily complete blood count (CBC)
Which of the following is most likely a clinical feature of obstructive sleep apnea? Blindness, Agnosia, Bradycardia and asthma, Daytime drowsiness
Daytime drowsiness
Hypoventilation
Decreased rate and depth; irregular
Which age-related change(s) increase the risk for complications after illness or injury in the older adult? (Select all that apply.)
Decreased skin elasticity, Fragile blood vessels, Altered pain and pressure perception, Decreased muscle strength and bone demineralization
A difference between the apical and radial pulse rates, called the pulse _______, indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.
Deficit
Treatment of Fever
Determining the cause of the fever and treating its underlying cause is an important part of patient care. result of a bacterial or other type of microbial infection, the appropriate antibiotic or anti-infective may be prescribed. Antipyretic (fever-reducing) drugs, such as aspirin, ibuprofen, or acetaminophen, may be administered in certain circumstances. Modifications of the external environment may be implemented to increase heat transfer from the internal to the external environment, including the use of cool sponge baths, cool packs, and hypothermia (cooling) blankets.
Which describes the best approach for the development of nursing diagnoses?
Develop nursing diagnoses from clusters of significant data.
Sources of stress two broad categories
Developmental and situational
Which of the following components of the nursing process is formed after completing a comprehensive nursing assessment?
Diagnosis
The nurse is assessing a cancer client's pain. The client is unable to point to a specific area of pain; rather, the client moves a hand over the abdomen to indicate the pain. What type of pain is this client experiencing?
Diffuse
four components of Informed Consent
Disclosure Comprehension Voluntary Competence
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?
Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?
Discuss with the client the need for assistance during ambulation.
A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.
Documenting entries that are up to date and comprehensive, Recording the date and time of all entries, Using approved agency abbreviations
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?
Does this task fall within the scope of a UAP?
A 40-year-old female client reports dull pain in the left breast. Before examining the client's breasts, using the wedge method, the nurse places the client in which position?
Dorsal recumbent with the arm of the side being examined above the head
Difficulty swallowing or the inability to swallow, known as ______ , is associated with an increased risk for aspiration.
Dysphagia
A nurse is caring for a client who has a right femur fracture that is currently in traction. The client has a prescription for hourly circulatory assessment. Which nursing assessment findings should be reported to the health care provider?
Edema and coolness to the right calf, Numbness and tingling to the right leg, Right capillary refill of 4 seconds (coolness, paleness, diminished pulse, impaired sensation such as numbness or tingling, muscle paralysis or extreme pain to the affected extremity.)
The therapeutic communication technique known as ___________ is the skill of identifying with the way another person feels.
Empathy
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?
Ensure that two fingers can be inserted between the restraint and the client's extremity.
The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?
Evaluate the use of current pain relief measures.
Which component of the nursing process includes determining reasons for unmet goals and providing modifications to ensure future goal completion?
Evaluation
The nurse is conducting a focused musculoskeletal and peripheral vascular assessment on a client. What should the nurse do first?
Examine range of motion
The nurse is conducting an initial cranial nerve assessment of a client with meningioma of the sphenoid ridge. Which actions should the nurse perform to assess cranial nerve I?
Examine the client's ability to smell., Test each nostril independently.
true or false A nasogastric or nasointestinal route is usually selected when nutritional support is needed for 4 to 8 weeks.
False
true or false Active euthanasia is defined as withdrawing medical treatment with the intention of causing the patient's death.
False
true or false An example of an open-ended question is: "What medicines have you been taking at home?"
False
true or false Interpersonal communication, or self-talk, is the communication that happens within the individual.
False
true or false Perceived loss is felt by the person and can be recognized by others.
False
true or false Stereotyping describes the feelings a person experiences when placed in a different culture.
False
true or false Vitamins C and B complex are absorbed with fat into the lymphatic circulation and stored mostly in the liver and adipose tissue.
False
true or false When a child who is angry with one's parents kicks a bedroom wall, the child is using the defense mechanism known as introjection.
False
true or false: Stress alone can cause autoimmune diseases such as rheumatoid arthritis.
False
true or false: The Patient Self-Determination Act of 1990 required all hospitals to conform to a standard, uniform set of advance directives.
False
The nurse working on the rehabilitation unit is examining the shoulders of a client during a detailed musculoskeletal assessment. Which four motions should be included during this examination?
Forward flexion, internal rotation, abduction, and external rotation.
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?
Gastrointestinal upset from food poisoning
1. When bathing a patient who requires contact and droplet precautions, which personal protective devices (PPD) will the nurse put on? (Select all that apply.)
Gloves, Gown, Mask.
The nurse places a bedpan under the buttocks of a client and asks the client to roll back over on the bedpan. What would be another method of having the client assist with getting on a bedpan?
Have the client flex his or her knees and lift the buttocks onto the bedpan
The process called __________ refers to the body's use of various physiologic mechanisms to respond to internal changes to maintain relative constancy in the internal environment.
Homeostasis
Which subjective questions by the nurse demonstrate a familiarity with commonly occurring disorders that can put an older patient at risk for unnecessary iatrogenesis? (Select all that apply.)
How well do you usually sleep?, Have you had any difficulty eating?, Is this the first time you have fallen?
Which of the following findings is most likely to be seen in patients with severe anxiety? Alogia, Fever, Cogwheel rigidity, Hyperventilation, Apraxia, Blurred vision
Hyperventilation
Shivering, a response that increases the production of heat, is initiated by the _____________ and results in muscle tremors, resulting in the production of heat.
Hypothalamus
Which statement by the nurse indicates a need for further education related to a focused neurovascular assessment on Edith Jacobson?
I am going to check the pulses in your unaffected limb.
A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?
Impaired memory
Which component of the nursing process involves engaging the patient and family with therapeutic communication to execute the nursing plan? Evaluation, Implementation, Interview, Support
Implementation
When should a health care facility determine its disaster preparedness plan for delivering care in the event of an emergency or disaster?
In advance of a possible emergency or disaster
When following the proper procedure for removing gloves that are a part of contact precautions, where should the first removed inverted glove be stored while the second glove is being removed?
In the palm of the gloved hand
Which of the following clinical features of a patient experiencing a panic episode? Inability to function or communicate, Adrenal fatigue, Dysrhythmia, Hypoventilation, Inability to wake from sleep, nystagmus,
Inability to function or communicate
Which of the following clinical features is most likely to be seen in patients with mild anxiety? Short attention span, Hallucinations, Increased alertness, Bizarre thinking and speech, Increase in only cortisol, Increased REM sleep
Increased alertness
Mild anxiety
Increased alertness, heighten perception (perceptual fields ) (e.g., vision and hearing) and motivates learning and growth
Alarm reaction neuroendocrine activity
Increased: heart rate, Blood pressure, peripheral vasoconstriction, metabolism, water retention, glucose. Dilated pupils, dilated bronchi, mental alertness. Flight-or-flight response.
Which of the following findings is most likely to be seen in patients with severe anxiety? Daytime sleepiness, Apraxia, Ineffective problem solving, Tardive dyskinesia, Papilledema, Nystagmus,
Ineffective problem solving
Severe anxiety
Ineffective problem-solving, automatic behavior and thought, hyperventilation; manifested by difficulty communicating verbally, increased motor activity, a fearful facial expression, headache, nausea, dizziness, tachycardia, and hyperventilation
The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first?
Inspect the skin, bones, and muscles of the entire posterior thorax.
Which nursing interventions will have the greatest impact on minimizing the spread of methicillin-resistant Staphylococcus aureus (MRSA) among patients on a surgical unit? (Select all that apply.)
Instituting meticulous handwashing technique, Implementing standard precautions, Using appropriate personal protective equipment (PPE)
When assessing a client's pain, what characteristic of pain does the nurse assess using a pain rating scale?
Intensity
Stessors may be
Internal (e.g., an illness, a hormonal change, or fear) or external (e.g., loud noise or cold temperature).
When considering a 40-year-old postoperative patient, which factor is likely to present the greatest risk for the development of an infection?
Invasive or indwelling medical procedures or devices
A nurse is documenting a client's care in the electronic health record. This is the third entry being made by the nurse for the day. The nurse would sign the entry using which signature?
J. Smith, RN
Which fall precautions should the nurse establish for Edith Jacobson after repositioning? (Select all that apply.)
Make the call light easily accessible., Educate the patient to use the call light if she needs to get up., Remind the patient that she is at high risk for falls due to her medications.
Mr. Griffin is receiving enoxaparin sodium therapy. Which assessment data would the nurse report to the patient's health care provider to ensure his postoperative safety?
Moderate amount of gum bleeding after completing oral hygiene
The nurse is caring for a client who is being admitted to the intensive care unit with bilateral pulmonary emboli. The client is reporting anxiety and apprehension. What would the nurse do?
Modify procedures as much as possible to limit stress., Note cultural influences that may influence individual response., Encourage client to express and acknowledge feelings.
Oculomotor (III) Nerve
Motor, all eye muscle except those supplied by 4 and 6
Vagus (X) Nerve
Motor: heart, lungs, bronchi, gastrointestinal tract. Sensory: heart, lungs, bronchi, trachea, larynx, pharynx, gastrointestinal tract, external ear
Glossopharyngeal (IX) nerve
Motor: pharyngeal musculature. Sensory: posterior part of tongue, tonsil, pharynx
Accessory (XI) Nerve
Motor: sternocleidomastoid and trapezius muscles
Trochlear (IV) Nerve
Motor: superior oblique muscle
When assessing a client, the nurse may identify which physiologic response to pain?
Muscle tension and rigidity
Wheeze (sibilant)
Musical or squeaking High-pitched, continuous sounds Auscultated during inspiration and expiration Air passing through fluid in the airways
Moderate anxiety
Narrow perception, short attention span, shaking; "butterflies in the stomach"
Which of the following is most likely a cause of obstructive sleep apnea? Nerve fiber demyelination, Narrowed or obstructed air passage, Air moving through fluid or mucous, Autoimmune
Narrowed or obstructed air passage
Stage of Resistance (GAS)
Neuroendocrine activity returns to normal Local adaptation syndrome (LAS) Coping and defense mechanisms.
Factors that distort the quality of the message, known as __________, can interfere with communication at any point in the process.
Noise
The nurse is caring for a client who was recently admitted to the cardiac care unit after open-heart surgery. The current assessment by the nurse reveals +0 pedal pulse on the left foot and +2 pedal pulse on the right foot. What should the nurse do first?
Notify the health care provider of this abnormal finding.
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
The emergency room nurse is conducting a focused thorax and lung assessment on a client reporting chest pain, cough, and dyspnea. Which assessment findings indicate the need for further assessment? Select all that apply.
Observed the client have a moist cough with production of yellow sputum, Auscultated low pitched, bubbling sounds during inspiration in right upper lobe
Which statement is true about transient bacteria? (Select all that apply.)
Occurs commonly on hands, Relatively few are found on clean areas of skin, Found in greatest numbers under the fingernails, Can be removed easily through frequent, effective hand washing.
motor nerves include
Oculomotor nerve (CN III), trochlear nerve (CN IV), abducens nerve (CN VI), accessory nerve (CN XI), hypoglossal nerve (CN XII).
sensory nerves include
Olfactory nerve (CN I), optic nerve (CN II), vestibulocochlear nerve (CN VIII)
Cranial nerve 1
Olfactory nerve (smell)
Which of the following is the most appropriate intervention used in the management of obstructive sleep apnea? Cryotherapy, Pericardiocentesis, Oral appliance, Nasal cannula
Oral appliance
During the ____________ phase of the helping relationship, the tone and guidelines for the relationship are established.
Orientation
What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?
Orienting clients to the surroundings decreases the potential for injury.
The nurse performs a focused musculoskeletal assessment on a patient with a hip fracture. Which should the nurse include for this type of assessment? (Select all that apply.)
Pain, Joint tenderness, Range of motion, Muscle weakness
While hospice care focuses on the needs of the dying, ___________ care is appropriate across the spectrum of disease and illness.
Palliative
The nurse is palpating a client's precordium. Which is an expected clinical finding?
Palpable pulsation over the mitral area
The nurse is performing a cranial nerve assessment on a client admitted with head trauma who is alert and oriented. Which actions should the nurse perform to assess cranial nerve 5?
Palpate the masseter and temporal muscles with the client's teeth clenched., Touch a cotton ball to the client's forehead, cheek, and jaw bilaterally.
The nurse is conducting a neurovascular assessment on a postoperative knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment?
Patient reports "pins and needles" sensation below the incision site.
Physical Effects of fever
Patients with fever may experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase. Young children with high fevers may experience seizures and older adults may have periods of confusion and delirium.
What actions are appropriate when donning personal protection equipment (PPE) for contact isolation? (Select all that apply.)
Perform hand hygiene., Put on gown, being sure to securely tie or fasten., Don gloves.
The nurse on a telemetry unit is performing morning assessments on the clients. Upon auscultation of an adult client's heart sounds, the nurse notes a scratchy, high-pitched sandpaper sound. How should the nurse document this sound?
Pericardial friction rub
The area around a person regarded as _________ space is the area into which others should not intrude during personal interactions.
Persona
An intimate communication zone occurs during interaction between parents and children, whereas a ___________ zone occurs when people interact with close friends.
Personal
The nurse is assisting the client with transfer to a bedside commode. After the client stands and pivots, what should the nurse instruct the client to do next?
Place hands on the armrests prior to sitting down.
The nurse has placed a urinal between the legs of a client and instructed him to place himself onto the urinal. After covering the client with the bed linens, what would be the nurse's next action?
Place the call bell and toilet paper next to the client and instruct him to call when he is finished.
The nurse has assisted the bedbound client to place the urinal between the legs. The nurse instructs the client to place the penis into the urinal. After covering the client with the bed linens, what would be the nurse's next action?
Place the call bell and toilet paper next to the client and instruct the client to call when finished urinating.
Which component of the nursing process involves setting goals?
Planning
Mr. Griffin's surgical care includes anticoagulation therapy. Which diagnostic blood count indicates a risk for spontaneous bleeding and should be reported to his health care provider immediately?
Platelet of < 50,000/μL
Which complications is Edith Jacobson at risk for because of her age and hip fracture? (Select all that apply.)
Pneumonia, Pressure ulcers, Mental deterioration
Which of the following is the most appropriate intervention used in the management of obstructive sleep apnea? Ballon thermotherapy, Combination drug therapy, Positional therapy, Lowest O2 therapy;
Positional therapy
Prior to placing the bedpan under a client's buttocks, what would the nurse apply to the bedpan if a urine specimen is not needed?
Powder
Which interventions will the nurse implement when maintaining medical asepsis? (Select all that apply.)
Practice good hand hygiene., Clean the least soiled areas first., Keep personal fingernails short., Do not place soiled bed linen on the floor.
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
In which stage of the development of an infection does the patient present the greatest risk to others?
Prodromal
What is the most important intervention the nurse can perform to prevent skin breakdown for clients using a bedpan?
Provide skin and perineal care after bedpan use.
An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching?
Put a small nightlight in the hall and stairway
The nurse is disposing the contents of the client's urinal. What is the correct procedure for cleaning the urinal?
Put on clean gloves, rinse the urinal with water, and dry with paper towel
The nurse is assessing a client's pain and asks the client, "What words would you use to describe your pain?" What characteristic of pain is the nurse assessing with this question?
Quality
Which statement best conveys the relationship between race and ethnicity?
Race denotes physical characteristics, while ethnicity is rooted in a common heritage.
The nurse is preparing to palpate a client's peripheral pulses. The nurse should plan to assess which pulses?
Radial, Popliteal, Posterior tibial, Dorsalis pedis, Brachial
Which of the following is most important when developing a plan of care using the nursing process? Resistance, Rotation, Realistic, Rate
Realistic
An older adult is admitted for a hip fracture and is confined to bed. What is the priority action by the nurse to decrease the risk of pressure ulcer?
Reposition the patient every two hours.
Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply.
Requesting native cuisine, Listening to folk music and dance, Asking to wear unique clothing
The three stages in GAS are the alarm reaction, the stage of _________, and the stage of exhaustion.
Resistance
Death is defined as the irreversible cessation of all functions of circulatory and ______________ functions, or irreversible cessation of all functions of the entire brain, including the brainstem.
Respiratory
Which piece of personal protection equipment (PPE) should be removed only after leaving the patient's room?
Respiratory mask
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?
Risk for Poisoning related to poor eyesight and the inability to read medication labels
Which of the following is a safety precaution most likely associated with the use of a walker?
Rubber tips for safety
lub
S1
dub
S2
What generalization can be made about safety in client care?
Safety is a paramount concern underlying all nursing care.
The client has had surgery to repair a left hip fracture. The client is asking to use the bedpan. How should the nurse assist the client onto the bedpan?
Seek assistance from another nurse to support the affected leg., Turn the client onto the unaffected leg to place the bedpan., Ensure the client's buttocks are resting on the shallow rim of bedpan.
Optic (II) Nerve
Sensory, eye, vision
Olfactory (I) Nerve
Sensory, nose, smell
Trigeminal (V) nerve
Sensory: face, sinuses, teeth, etc. motor: muscles of mastication
Which of the following clinical features is most likely to be seen in patients with moderate anxiety? Shaking, Ineffective problem solving, Hallucinations, Autonomic behavior, Hyperventilation, Increased REM sleep,
Shaking
Which of the following clinical features is most likely to be seen in patients with moderate anxiety? Somnolence, Apraxia, Daytime sleepiness span, Short attention span, Trichotillomania, Taste change,
Short attention span
alarm reaction (GAS)
Short term (minutes to hours); initiated when a person perceives a specific stressor and various defense mechanisms are activated.
In what position would the nurse place a female client who is using a bedpan?
Sitting upright
Which of the following is most likely indicated when using a walker?
Sizing walker
The nurse places a frail older adult client on the bedpan. After the client has voided and the nurse has removed the bedpan, what assessment is necessary for the nurse to complete?
Skin assessment of the buttocks and coccyx
Rhonchi (sonorous wheeze)
Sonorous or coarse; snoring quality Low-pitched, continuous sounds Auscultated during inspiration and expiration Coughing may somewhat clear sound Air passing through or around secretions Tend to be louder in expiration
A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?
Subjective
Which of the following is the most appropriate intervention used in the management of obstructive sleep apnea? Cold knife conization, Hyperbaric oxygen, Surgery, Balloon atrial septostomy
Surgery
An older adult patient has been admitted for a hip fracture. The nurse is assessing fall risk with a fall risk tool. What essential elements should the tool assess? (Select all that apply.)
Symptoms of dizziness, High-risk medications, Mental and emotional status, Altered elimination
The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?
The alternative measures attempted before applying the restraints
Remittent Fever
The body temperature does not return to normal and fluctuates a few degrees up or down.
Sustained or Continuous Fever
The body temperature remains above normal with minimal variations.
Intermittent Fever
The body temperature returns to normal at least once every 24 hours
Relapsing or Recurrent Fever
The body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days.
The nurse recognizes that an example of a cognitive outcome is:
The client identifies three foods high in potassium by August 8.
The nurse performs a situational assessment for a client with a high risk of injury. Which findings during this assessment require the nurse to act? Select all that apply.
The client is confused as to why the call bell won't call home., The client needs the assistance of two staff when getting out of bed., The client's adult child places shoes and a cane next to the raised bed rail.
The nurse typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding causes the nurse to perform this assessment rather than delegate it?
The client went to the emergency department to be evaluated after a fall
Evaporation
The conversion of a liquid to a vapor; example, Body fluid in the form of perspiration and insensible loss is vaporized from the skin.
allostatic load
The cumulative negative effects of these physical responses to prolonged environmental and psychosocial stressors
Radiation
The diffusion or dissemination of heat by electromagnetic waves; example, the body gives off waves of heat from uncovered surfaces
Convection
The dissemination of heat by motion between areas of unequal density; example, An oscillating fan blows currents of cool air across the surface of a warm body.
Korotkoff Sounds Phase 5
The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure
When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?
The nurse should determine the client's normal bowel elimination pattern.
A dying client requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this client?
The nurse should select a formal prayer or Bible passage to use to pray aloud.
What is the priority outcome for Edith Jacobson in relationship to her hip fracture?
The patient will be able to walk with an assistive device without the fear of falling
Devices such as pillows, trapeze bars, special mattresses, and trochanter rolls are used for what primary purpose?
To alleviate pressure and maintain proper body alignment
Edith Jacobson needs to be frequently repositioned. Why should the task take two people?
To prevent additional injury to the patient
The nurse is caring for a client who has a prescription for strict intake and output measurements. The client wants to use the bedside commode. What is most important for the nurse to instruct the client?
Toilet tissue should not be placed in the commode as it may affect accurate measurement
The nurse is caring for a client admitted with degenerative disease of the cervical spine. The client reports moderate pain. During the inspection phase of the musculoskeletal assessment, what should the nurse expect to find?
Torticollis
Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?
Tracheobronchial suctioning
Ninety-five percent of the lipids in the diet are in the form of ______ , the predominant form of fat in food and the major storage form of fat in the body.
Triglycerides
True or false: Tachycardia occurs in an adult when the pulse rate is 100 to 180 beats/minute.
True
true or false A crisis is a disturbance caused by a precipitating event, such as a perceived loss, a threat of loss, or a challenge that is perceived as a threat to self.
True
true or false Carbohydrates are more easily and quickly digested than protein and fat.
True
true or false During Engel's stage of grief known as idealization, there is often an exaggeration of the good qualities that the deceased person possessed.
True
true or false Ethnicity is a sense of identification with a collective cultural group based on the group's common heritage.
True
true or false Ethnocentrism is the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture.
True
true or false Height and weight are the most common anthropometric measurements used to determine body dimensions.
True
true or false In the exhaustion stage of general adaptation syndrome (GAS), without defense against the stressor, the body may either rest or mobilize its defenses to return to normal or reach total exhaustion and die.
True
true or false Incivility is rude, disruptive, intimidating, and undesirable behavior directed at another person.
True
true or false One of the most culturally variable forms of nonverbal communication is eye contact.
True
true or false Rapport refers to a feeling of mutual trust experienced by people in a satisfactory relationship.
True
true or false The major sources of stress in our society arise from interpersonal relationships and performance demands rather than from actual physical threats.
True
true or false: Based on the theory that carbohydrates make tryptophan more available to the brain, a nurse should offer a patient a small protein- and carbohydrate-containing snack at bedtime.
True
true or false: The core body temperature is maintained within a fairly constant range by the thermoregulatory center in the hypothalamus.
True
true or false: The nurse should know that a systolic blood pressure reading greater than 100 mm Hg is abnormal in a toddler.
True
A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?
Unless contraindicated, nurses should encourage clients to stand to use a
Which would be the best choice of a device for urinary elimination for a 42-year-old male client who is on bed rest following knee surgery?
Urinal
The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?
Use a safety monitoring device.
What should the nurse anticipate needing to teach Edith Jacobson before discharge in relationship to her hip fracture and mobility?
Use of assistive devices such as a walker
The nurse is helping to clean a female client who has urinated into a bedpan. What is the recommended guideline for this action?
Use toilet paper to wipe the client from the pubic area to the anal area.
Stage of Exhaustion (GAS)
Vasodilation, Decreased Blood pressure, increased pulse and respiration. Panic, crisis.
Which of the following are patient education points associated with using a walker?
Walker with affected leg
Which of the following is the most appropriate recommendation in a patient with obstructive sleep apnea? Inhaler use at night, Weight loss, Antihistamine, Closely monitor glucose levels
Weight loss
Which factors increase a postoperative patient's risk of infection? (Select all that apply.)
Weight, Age, Presence of an incision, Immunosuppression
The nurse is caring for a female client who has used a bedside commode. The client requires assistance with personal care after voiding. How should the nurse assist the client with personal hygiene?
Wipe using one stroke from the pubic area toward the anal area.
afebrile
a condition in which the body temperature is not elevated; A person with a normal body temperature
fear
a feeling of dread; a cognitive response to a known threat
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
a flow sheet
Negative feedback system
a process that results in a response that reverses the original stimulus
Adaptation
adjustment of living with other living things and environmental conditions
If it travels from the periphery to the brain, then it is
afferent (sensory) nerve.
An atheist is a person who denies the existence of a higher power; an _________ is one who holds that nothing can be known about the existence of a higher power.
agnostic
three stages in the GAS
alarm reaction, stage of resistance, and stage of exhaustion
Which of the following substances is primarily absorbed in the stomach? magnesium, cobalamin, alcohol, folate, fluids and fiber, iron
alcohol
specific effect of stressors
alteration of normal body structure and function
reflex depends on
an intact, functioning neurologic reflex arc and involves both sensory and motor neurons.
most common human response to stress
anxiety
associated phenomena
any factors consistently related to the pain
Stressor
anything causing a person to experience stress; change in the balanced state
Sleep _________ is a sleep-disordered breathing condition in which breathing may cease for as long as 2 minutes.
apnea
not be taken by anyone younger than 19 years during fever-causing or flu-like illnesses
aspirin and combination products containing aspirin
Which interventions will help minimize the risk of infection postoperatively? (Select all that apply.)
assessing vital signs (especially for fever); maintaining hydration; maintaining nutritional status; encouraging a diet high in proteins, carbohydrates, calories, and vitamins; using proper hand hygiene; and following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains.
reflex pain response:
automatic response of the central nervous system to the stimulus of pain
Paroxysmal nocturnal dyspnea
awakening from sleep with dyspnea (shortness of breath) and needing to be upright to achieve comfort.
The condom and diaphragm are examples of the ____________ method of contraception.
barrier
Which of the following processes most notably occurs in the terminal ileum? folate resorption, bile resorption, water resorption, alcohol resorption, iron resorption, magnesium resorption
bile resorption,
Hypertension
blood pressure elevated above the upper limit of normal; A diagnosis of hypertension is made when the systolic pressure is 130 mm Hg or higher or the diastolic pressure is 80 mm Hg or higher
During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:
body systems.
vital signs
body temperature, pulse and respiratory rates, and blood pressure; synonym for cardinal signs; indicators of physiologic functioning and reflect the health status of a person.
The religion known as _____________ teaches that there are "Four Noble Truths" that indicate the range of "suffering," its "origin," its "cessation," and the "way" that leads to its cessation.
buddhism
renin-angiotensin-aldosterone system, through angiotensinogen II effects on blood pressure
causes vasoconstriction in the arterioles. This leads to increased peripheral vascular resistance as a short-term mechanism, and also increases sodium and water retention by the kidneys to increase circulatory fluid volume, thus increasing blood pressure as a long-term mechanism
Physiologic effects of stress include
changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations
shock phase of the alarm reaction
characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness.
Primary physiologic stressors include
chemical agents (drugs, poisons), physical agents (heat, cold, trauma), infectious agents (viruses, bacteria), nutritional imbalances, hypoxia, and genetic or immune disorders.
Oral site for temperature not suitable for use with
children less than 5 years old, for some children with developmental delay, with patients who are unable to follow directions, or for confused and comatose patients, patients with diseases of the oral cavity, in those who have surgery of the nose or mouth, or when there is a risk of seizures, and patients receiving oxygen by mask
During your assessment of a patient with a fever, which of the following is most likely to be seen? Congestion, Visual Disturbances, Chills, Sore throat, sneezing, paresthesias
chills
A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:
client will participate in self-care measures by the end of the week.
S2
closure of the aortic and pulmonic valve; beginning of diastole;
S1
closure of the mitral and tricuspid valve; beginning of systole ; when those valves close, the ventricles contract and send the blood out of the heart.
Febrile
condition in which the body temperature is elevated
Stress
condition in which the human system responds to change in its normal balanced state
Task-oriented reactions involve
consciously thinking about the stress situation and then acting to solve problems, resolve conflicts, or satisfy needs. These reactions include attack behavior, withdrawal behavior, and compromise behavior.
Visual acuity is which cranial nerve
cranial nerve 2 (II)
Extraocular movements are assessed with which cranial nerve
cranial nerve 3 (III)
Size and shape of pupil is which cranial nerve
cranial nerve 3 (III)
Ability to masticate food is which cranial nerve
cranial nerve 5 (V)
Strength of ocular muscles is which cranial nerve
cranial nerve 6 (VI)
Which of the following is a lifestyle modification that is commonly recommended to patients with hypertension? propranolol, limit protein in diet, diet changes, limit mobility, avoid acid-producing foods, high calorie, high protein diet
diet changes,
Body temperature
difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees.
pulse deficit
difference between the apical and radial pulse rates
The nurse should immediately report bradycardia associated with
difficult breathing, changes in level of consciousness, decreased blood pressure, electrocardiogram (ECG) changes, and angina (heart pain).
The nursing diagnosis of spiritual _________ can be used to describe the impaired ability to experience and integrate meaning and purpose in life through one's connectedness with such things such as self, others, art, and music.
distress
Tympanic membrane temperature contraindication
drainage from the ear, ear pain, ear infection, or scars on the tympanic membrane.
Which of the following is a major site of iron absorption? jejunum, duodenum, colon, rectum, esophagus, ileum
duodenum
A ___________ power of attorney appoints an agent whom the person trusts to make decisions in the event of subsequent incapacity.
durable
What four elements have to be present in order for malpractice to occur?
duty, breach of duty, Causation, Damages
People who have gender ____________ are those whose biologic sex at birth is contrary to the biological sex with which they identify.
dysphoria
if the information goes from the brain to the periphery, then it is
efferent (motor) nerve.
Pyrexia
elevation above the upper limit of normal body temperature; synonym for fever
Fever
elevation above the upper limit of normal body temperature; synonym for pyrexia
Which of the following is a lifestyle modification that may be recommended to patients with hypertension? medical alert bracelet, lifelong replacement hormone, encourage self monitoring, maintain lifestyle as usual, monitor for bleeding and infection, glucose monitoring
encourage self monitoring,
When a home-bound client expresses the client's past-oriented ancestral heritage and family rituals, the nurse recognizes that the client is expressing:
ethnic identity.
Midsystolic click
extra heart sound usually found with mitral valve prolapsed not associated with a scratchy noise.
The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?
extremity restraint
cranial nerve 7
facial nerve
Alleviating factors
factors that make the pain go away or lessen
Aggravating factors
factors that make the pain occur or increase in intensity
What is the leading cause of injury-related deaths in adults 65 and older?
falls
True or false: The axillary site is considered to be one of the most accurate routes for assessing temperature.
false
true or false Faith is a confident belief in something for which there is no material evidence or proof.
false
true or false In the excitement phase of the sexual response cycle, desire and arousal continue to build and intensify, leading to orgasm.
false
true or false Masochism refers to the practice of gaining sexual pleasure while inflicting abuse on another person.
false
true or false When providing care to people from different cultures, it is important to allow past experiences to guide solutions to all cultural situations.
false
true or false: During stage II NREM sleep, a person reaches the greatest depth of sleep; arousal is very difficult in this stage.
false
true or false: REM sleep, believed to be essential to mental and emotional equilibrium, consumes about 55% of a person's sleep time.
false
Hippocrates
father of medicine
Claude Bernar
father of physiology
Closely related to spirituality, faith, and religion, ______ is the ingredient in life responsible for a positive outlook even in life's bleakest moments.
hope
A nursing diagnosis related specifically to spirituality would be __________, a subjective state in which a person sees limited or no alternatives or personal choices available and is unable to mobilize energy on one's behalf.
hopelessness
Chronology of pain
how the pain develops and progresses.
Which of the following is a major site of folate (vitamin B9) absorption? esophagus, terminal ileum, descending colon, transverse colon rectum, jejunum
jejunum
A good exercise for women in developing body awareness is the use of ________ exercises, which promote good vaginal tone by localizing and strengthening the pubococcygeal muscle.
kegel
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?
largest part of a regular bedpan should be placed under the client's buttocks.
diastolic pressure
least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
Besides being an instrument of continuous client care, the client's health care record also serves as a(an):
legal document.
inflammatory response:
localized response of the body to injury or infection; protective mechanism that eliminates invading pathogens and allows for tissue repair to occur
local adaptation syndrome (LAS):
localized response of the body to stress, precipitated by trauma or pathology; short term adaptive response
Illness-related tasks include
losing independence and control, handling pain and disability, and carrying out the prescribed medical regimen
Hypothermia
low body temperature
general tasks (as in the case of any situational stress) involves
maintaining self-esteem and personal relationships and preparing for an uncertain future.
Crises may be
maturational, situational, or adventitious
Which of the following is commonly recommended to patients with hypertension? medications, amiodarone, monitor serum protein levels, avoid antacids, high calorie, high protein diet, flecainide
medications
Based on the circadian cycle, the body releases __________, a natural chemical produced at night that decreases wakefulness and promotes sleep.
melatonin
four levels of anxiety
mild, moderate, severe, and panic
Which of the following is most likely an intervention associated with the treatment of a fever? administer antihistamine, limit fluid intake, monitor electrolytes and fluid, mobilize ASAP, NPO until fever breaks, NPO except fluids
monitor electrolytes and fluid,
Which of the following is most likely an intervention associated with the treatment of a fever? monitor feeding, mobilize ASAP, monitor viral signs, especially temperature, monitor glucose, NPO except fluids, Avoid Hot foods
monitor viral signs, especially temperature
Abducent (VI) Nerve
motor: external rectus muscle
Facial (VII) nerve
motor: muscles of the face
Hypoglossal (XII) Nerve
motor: muscles of the tongue
Ventilation (or breathing)
movement of gases in and out of the lungs
Rectal temperature contraindication
newborns, children with diarrhea, and in patients who have undergone rectal surgery or have a disease of the rectum and patients with heart disease or after cardiac surgery, and neutropenic (have low white blood cell counts, such as in leukemia) and in patients who have certain neurologic disorders (e.g., spinal cord injuries). Do not insert a rectal thermometer into a patient who has a low platelet count
Eupnea
normal respirations
Inspiratory stridor
obstructed airway and often with respiratory infections such as croup.
What are the nursing responsibilities in the Informed Consent process?
obtain a client's consent for nursing measures undertaken
Maturational crises
occur during developmental events that require role change, such as when a teenager transitions into adulthood.
Situational crises
occur when a life event disrupts a person's psychological equilibrium, such as loss of a job or death of a loved family member.
cranial nerve 2
optic nerve
cardiovascular center transmits
parasympathetic impulses to the heart via the vagus nerve and sympathetic impulses to the heart and blood vessels via the spinal cord and peripheral sympathetic nerves. Stimulating the vagus nerve slows the heart rate; sympathetic stimulation increases the heart rate.
Total _______ nutrition provides complete nutrition intravenously, bypassing the gastrointestinal tract for patients who are unable to take fluid orally.
parenteral
coping mechanisms:
patterns of behavior used to neutralize, deny, or counteract anxiety
auscultatory gap
period of diminished or absent Korotkoff sounds; it occurs during the manual measurement of blood pressure in the latter part of phase I and during phase II
psychosomatic disorder:
physiologic alterations and illness believed to be due to psychological influences
Physical Effects of Hypothermia
poor coordination, slurred speech, poor judgment, amnesia, hallucinations, and stupor. Respirations decrease and the pulse becomes weak and irregular with lowering blood pressure.
The nurse is assisting a client who is immobilized with a neck injury to use a bedpan for urinary elimination. What is one of the primary nursing goals when assisting a client with urinary elimination?
promote comfort and normalcy with urinary elimination.
Which of the following is most likely an intervention associated with the treatment of a fever? avoid hot foods, NPO except fluids, administer antihistamine, mobilize ASAP, NPO until fever breaks, provide adequate fluids
provide adequate fluids
Anticipatory guidance focuses on
psychologically preparing a person for an unfamiliar or painful event.
Mechanisms of heat transfer
radiation, convection, evaporation, and conduction.
When assessing cranial nerve 7 (VII) ask the patient to
raise eyebrows, puff out cheeks, and smile; or taste foods
Tachycardia
rapid heart rate; rapid heart rate, decreases cardiac filling time, which, in turn, decreases stroke volume and cardiac output. An adult has tachycardia when the pulse rate is 100 to 180 beats/min
tachypnea
rapid rate of breathing; >24 breaths/min Shallow
Characteristics of the peripheral pulse include
rate, rhythm, and amplitude (quality; strong or weak).
Temperature
refers to the hotness or coldness of a substance
the two most common responses that influence nursing care
reflex pain response and the inflammatory response.
Vasopressin (ADH) effects on blood pressure
released from the posterior pituitary when stimulated by decreased blood volume and blood pressure, or by an increased osmolality of body fluids. It has a direct vasoconstricting effect on blood vessels, increasing peripheral resistance.
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
Two systems in the brainstem, the ___________ activating system and the bulbar synchronizing region, are believed to work together to control the cyclic nature of sleep.
reticular
Treatment of Hypothermia
rewarming the patient. Rewarming can be accomplished by covering with additional clothing and blankets, the use of heating blankets and pads, and radiant warmers. Warm fluids are administered either orally or through the intravenous route.
When performing a situational assessment, which assessment would the nurse complete as the last step?
safety survey
The bell of the stethoscope is useful for hearing
screens out high-frequency sounds and is more useful for hearing low-frequency sounds, such as those commonly made by the heart and the blood within the vessels.
Vestibulocohlear (VIII) nerve
sensory: inner ear
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released
Eustress
short-term stress that promotes positive emotional, intellectual, and physiologic adaptation and development.
Bradycardia
slow heart rate; pulse rate below 60 beats/min in an adult.
Bradypnea
slow rate of breathing; <10 breaths/min Regular
Which of the following is a lifestyle modification that is commonly recommended to patients with hypertension? smoking cessation, maintain same diet, maintain lifestyle as usual, carry inhaler, limit protein in diet, high sodium diet
smoking cessation,
Physiologic stressors have both a
specific effect and a general effect.
Which of the following is most likely an intervention associated with the treatment of a fever? Warm blankets, isolation precautions, airborne precautions, sponge bath with tepid water, limit fluid intake, droplet precautions
sponge bath with tepid water,
Which of the following is a major site of alcohol absorption? terminal ileum, jejunum, stomach, oral cavity, colon, esophagus
stomach
general effect of stressors
stress response
caregiver burden
stress responses experienced during prolonged periods of home care by family caregivers
basic concepts of stress and adaptation include:
stress, stressors, adaptation, and homeostasis
During your assessment of a patient with a fever, which of the following is most likely to be seen? sore throat, polyphagia, visual disturbances, pain with defecation, sweating, increased appetite
sweating
Benign murmur
swooshing sound that is usually developmental and outgrown with aging
Epinephrine effects on blood pressure
sympathetic neurotransmitter, is released by the adrenal gland to increase heart rate and contractility, thereby increasing cardiac output.
People with the sexually transmitted infection known as ___________ can be asymptomatic for as long as 20 years while damage continues to occur to their neurologic and cardiovascular organs.
syphilis
Coping mechanisms often used at higher levels of anxiety are categorized as
task-oriented reactions.
orthostatic hypotension
temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension; a decrease in systolic blood pressure of ≥20 mm Hg or a decrease in diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position
Which of the following is a major site of cobalamin (vitamin B12) absorption? Rectum, Duodenum, Terminal ileum, esophagus, oral cavity, jejunum
terminal ileum
inspiration (or inhalation)
the act of breathing in
expiration (or exhalation)
the act of breathing out.
Diffusion
the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood.
Perfusion
the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells.
Pulse oximetry
the noninvasive measurement of arterial oxyhemoglobin saturation, is also often included with the measurement of vital signs
Pulse rhythm
the pattern of the beats and the pauses between them
allostasis
the process of achieving stability or homeostasis through physiologic or behavioral change
Therapeutic hypothermia
the purposeful lowering of the core body temperature, has been used to improve outcomes after cardiac arrest. This decreased body temperature reduces metabolic rate and oxygen demand of the body to improve survival and neurologic outcomes
Pulse Amplitude (Quality)
the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. 0: absent, unable to palpate +1: Diminished, weaker than expected. +2: Brisk, expected (normal). +3: Bounding
The nurse is completing a situational assessment. Which findings would cause the nurse concern? skin bluish color, IV infusing incorrectly, spilled water on floor, oxygen worn incorrectly
the skin is a bluish-color., The IV is not infusing at the correct rate., There is spilled water on the floor., The client is wearing the oxygen around the neck
For which clients would a fracture bedpan be the most comfortable choice for urinary elimination?
thin, elderly female client with pneumonia
beta-adrenergic blockers
to block sympathetic stimulation and decrease cardiac output
angiotensin-converting enzyme (ACE) inhibitors
to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production)
vasodilators and calcium channel blockers
to relax smooth muscles of arterioles and decrease peripheral vascular resistance)
The nurse is caring for a female client who has used the bedside commode. What things should the nurse document for this client? (SATA)
tolerance of activity, characteristics of urine and/or stool, alterations in skin integrity
Lateral jaw movements are the motor function of the
trigeminal nerve
Mixed nerves (sensory and motor) include
trigeminal nerve (CN V), facial nerve (CN VII), glossopharyngeal nerve (CN IX), vagus nerve (CN X).
cranial nerve 4
trochlear nerve (eye movement)
Members of the religion Jesus Christ of Latter Day Saints (Mormons) believe in divine healing through the "laying on of hands."
true
Nurses always have the moral right to withdraw from administering care that violates their personal moral code.
true
true or false An emergency department nurse is aware that those who practice the religion of Jehovah's Witnesses will not accept blood transfusions.
true
true or false Coitus interruptus, one of the oldest and most widely used contraceptive methods, usually results in a 27% pregnancy occurrence.
true
true or false Communication is influenced by the way people value themselves, one another, and the purpose of any human interaction.
true
true or false LGBT youth are two to three times more likely to attempt suicide.
true
true or false Obesity is defined as body weight 20% or more above ideal weight or having a body mass index (BMI) of 30 or more.
true
true or false Spirituality is anything that pertains to a person's relationship with a nonmaterial life force or higher power.
true
true or false The most significant difficulty that a hypertensive person faces regarding sexuality is that medication used to control the disease frequently causes a change in sexual functioning
true
true or false: Recent research has indicated a possible cause-and-effect relationship between sleep deprivation and obesity, cancer, diabetes, and cardiovascular conditions.
true
true or false: The definitive treatment of moderate or severe obstructive sleep apnea involves use of a continuous positive airway pressure machine (CPAP).
true
Orthopnea
type of dyspnea in which breathing is easier when the patient sits or stands
The corneal reflex should only be assessed with which type of patient
unconscious client.
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
urine output 100 ml
Wong-Baker Faces pain rating scale
used for adults and children over three years old.
FLACC scale
used for infants and children (2 months to 7 years) who are unable to validate the presence of or quantify the severity of pain
COMFORT scale
used for infants, children, and adults who are unable to use the Numeric Rating Scale or Wong-Baker Faces pain rating scale
