fundamentals test 3

Which is a normal specific gravity for urine?

1.02

intensity

1-10 scale, severe, mild, moderate

Which best describes a client who is obtunded?

A client with a low level of awareness to his or her environment

What would the nurse anticipate a health-care provider to prescribe to a client having a seizure for 10 minutes?

Diazepam (Valium)

The nurse is preparing to irrigate the ear of a 2-year-old toddler. In which position should the nurse position the child's ear?

Down and back

Which stimulates an infant's tactile senses?

Holding and cuddling

A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling?

Check on the client every 2 hours and offer toileting assistance.

A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe?

Clean-catch specimen

The health-care provider prescribes mu agonist opioids for a client with terminal cancer who needs pain management for breakthrough pain. What is the rationale for this prescription?

Mu agonist opioids control pain in between long-acting pain medications.

How would the nurse assess for costovertebral angle tenderness?

Percuss between the 12th rib and spine.

Which condition in older men can result in impaired flow of urine from the bladder into the urethra?

Prostatic hypertrophy

What is the purpose of using a drape when inserting a catheter?

Provides privacy for the client

What anatomical feature makes women more prone to urinary tract infections than men?

Proximity of the urethra to the vagina and anus

Which describes perception?

The ability to interpret impulses transmitted from the receptors that give meaning to the stimuli

The nurse is developing a plan of care for a client with new hearing aids. Which long-term goal is most appropriate for the client?

The client will demonstrate how to properly care for the hearing aids within 2 weeks.

pain modulation

changing pain perception

transmission

conduction of pain message to spinal cord

periodicity

constant, intermittent

radiating/referred

moves

neuropathic

nerve ending pains

psychogenic

not an organic reason for the pain (the pain is in your head)

intractable

off and on and usually very intense

cutaneous/superficial

on skin

phantom

pain of a part of body that is not there

nociceptive

pain receptors that gather info and send it to CNS and to brain to process

acute

pain that lasts less than 6 months

chronic

pain that lasts more than 6 months

quality

sharp, throbbing, dull, etc

factors that influence pain

emotions past experiences with pain developmental stage sociocultural factors communication skills cognitive impairments

visceral

generalized pain

Which ion controls acid-base balance?

hydrogen

Which factors place female clients at higher risk for urinary tract infections? Select all that apply.

-Pregnancy -Menopause -Sexual activity

The nurse is speaking with a client who is confused and is getting agitated. Which communication technique is most appropriate when the client asks about the whereabouts of his or her spouse who has been deceased for 3 years?

"You must miss your husband."

Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply.

-Prevent infection -Maintain skin integrity. -Maintain the free flow of urine.

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply.

-Leakage of urine -Nocturnal frequency of urine -Bladder infections

The nurse just finished inserting an indwelling urinary catheter into a client and is sitting down to document the procedure. Which information should the nurse include in the medical record? Select all that apply.

-Catheter size -Date and time of insertion -Amount of saline in balloon -Color, clarity, and amount of urine return

The nurse is providing discharge teaching for a client who will be taking a loop diuretic. What should the nurse include in the teaching? Select all that apply.

-Change positions slowly. -Report any muscle weakness. -Notify the health-care provider of any rash.

The nurse educator is teaching a group of nurses about pain control in older adults. What should the nurse include in the presentation regarding older clients reporting pain? Select all that apply.

-Cognitive impairment can impair the ability to report pain. -Discomfort may only be evident in nonverbal signs such as grimacing.

The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply.

-Creatinine -Blood urea nitrogen (BUN)

Which physiological factors can place an 83-year-old client at risk for acute kidney injury? Select all that apply.

-Decline in glomerular function -Arteriosclerotic blood vessel changes

Which can occur as a result of sensory decline in older adults? Select all that apply.

-Depression -Social isolation -Hallucinations

Which interventions would be most appropriate to include in the plan of care for a client with visual deficits? Select all that apply.

-Describe the layout of the room. -Introduce yourself when entering the room. -Explain the unfamiliar sounds such as alarms.

Which are conditions that can affect sensory organs? Select all that apply.

-Diabetic retinopathy -Hypertension -Sickle cell disease

Which strategies are often effective in relieving anxiety and fear in clients with dementia? Select all that apply.

-Establish a predictable routine. -Use the same caregivers each day if possible -Use alternative therapies

Which types of mechanical stimuli that leads to pain would the nurse find in a client who is bedridden? Select all that apply.

-Friction -Pressure -Shearing

What clinical manifestations might a nurse expect to see if a client has impaired renal function? Select all that apply.

-High blood pressure -Altered mental status -Fluid retention

The nurse is giving a lecture regarding ways to promote optimal cognitive health to a group of retirees in a senior center. What information should the nurse include? Select all that apply.

-Include leisure activities in your life. -Consume a balanced and nutritious diet. -Incorporate physical activity into your day.

Which factors affect how a person responds to a stimulus? Select all that apply.

-Intensity -Contrast -Adaptation -Previous experience

Which strategies might be effective at preventing sensory overload in ICU clients? Select all that apply.

-Keep lights low at night. -Reduce sounds in and around the area. -Limit the number of times the client must be awakened.

The nurse is caring for a client undergoing chemotherapy. The client reports heightened olfactory sensitivity during treatment. Which interventions would help alleviate the problem for the client? Select all that apply.

-Keep wounds covered. -Use deodorizing sprays. -Promptly empty the commode.

Which areas of the brain are stimulated by the hypothalamus when a person experiences pain? Select all that apply.

-Limbic system -Somatosensory cortex

Which are examples of adaptation? Select all that apply.

-Living next to a train track and not being bothered by the sound of the train after a period of time -Not hearing a loud ticking of a clock after hearing it over time

Which factors affect the perception of a stimulus? Select all that apply.

-Location of the receptors -Number of receptors activated -Frequency of action potentials generated -Changes in frequency, location, and number of stimuli

Which are examples of types of receptors in the body? Select all that apply.

-Mechanoreceptors -Photoreceptors -Chemoreceptors

Which factors could cause a person to develop a partial seizure? Select all that apply.

-Meningitis -Head trauma -Brain tumors -Sleep deprivation

What should the nurse include in the post-procedure care for a client who underwent a cystoscopy? Select all that apply.

-Monitor intake and output. -Assess color and clarity of urine.

Which are ways pain is classified and described? Select all that apply.

-Origin -Intensity -Quality

The nurse is admitting a client to the hospital with new onset seizure disorder. What should the nurse delegate to the nursing assistive personnel (NAP) to do for the client? Select all that apply.

-Pad the siderails. -Place oral suction at the bedside.

Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply.

-Removes ammonia from blood -Hydrogen ions secreted to help maintain normal blood pH -Removes creatinine from the blood

Which functions of the kidney are considered secondary functions? Select all that apply.

-Renin production -Vitamin D activation -Erythropoietin secretion

The home health nurse just removed an indwelling urinary catheter from a client per the health-care provider's order. Which instructions should the nurse provide the client? Select all that apply.

-Report any pain or burning upon urination. -Increase oral fluid intake to promote urine production. -Contact the health-care provider if unable to urinate 8 hours after catheter removal.

A nurse is assessing a urostomy on a client. She should be most concerned about which findings? Select all that apply.

-Sloughing of skin -Skin breakdown -Encrustation

The nurse is educating a group of clients in a community center about the use of over-the-counter pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). What information would be most important to include? Select all that apply.

-Take NSAIDs with food or meals. -Use of aspirin can prolong bleeding time. -Use of ibuprofen is safer than prescription NSAIDs.

A client with Parkinson's disease reports difficulty with balance. Which types of exercise would help with this client's kinesthetic deficits? Select all that apply.

-Yoga -Tai chi -Flexibility activities

The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply.

-Urine -Emesis -Diarrhea -Nasogastric drainage

The nurse is educating a client with type 1 diabetes mellitus how to prevent injuries related to peripheral neuropathy. Which should be included in the teaching plan? Select all that apply.

-Wear properly fitting shoes. -Change positions on a frequent basis.

The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity. Which clinical manifestations should the nurse instruct the family to report? Select all that apply.

-Withdrawal -Depression -Hallucinations -Social isolation

The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon?

30 mL

In which client would patient-controlled analgesia (PCA) be contraindicated?

A 75-year-old client with a history of Alzheimer's disease who fell at home

According to the gate-control theory of pain, which type of fibers inhibit the client's perception of pain?

A-delta fibers

A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss?

Antidiuretic hormone (ADH)

Which is an advantage of intermittent catheterization over indwelling catheters?

Can be removed immediately and client can void normally

Which laboratory test should be performed prior to a client undergoing a renal biopsy?

Coagulation studies

Which part of the kidney is made up of millions of functional units called nephrons?

Cortex

The client with a diagnosis of multiple myeloma calls the nurse and reports pain of 9 on a scale of 0 to 10 and requests something for the pain. Which type of pain would the nurse document in the health record?

Deep somatic pain

A nurse is inserting an indwelling catheter into a client. She begins to inflate the balloon, she feels resistance, and the client complains of discomfort. Which action should the nurse take?

Deflate the balloon and advance the catheter about an inch before attempting again.

A client presents to the emergency department with nausea and vomiting for 2 days. The client states he or she has not urinated at all for the past 8 hours. Which is the most likely cause of his lack of urine output?

Dehydration

A nurse is placing an indwelling catheter in an obese female client and realizes that the catheter is in the vagina rather than the urinary meatus. Which action should the nurse take?

Discard the catheter, adjust the client's position and lighting, and try again with a new catheter.

Which nursing action can manage unpleasant olfactory stimuli?

Emptying commodes and bedpans immediately

A client admitted with pneumonia informs the nurse of a preference for complementary medicine treatment. Which oil could the nurse suggest the family bring in for the client?

Eucalyptus

The nurse asks a client who underwent a hip replacement to rate his or her pain level. The client states it is a 6 on a scale of 0 to 10 but is fine with this level and does not want pain medication. What should be the nurse's next action?

Explain it is better to take medication when pain is minimal.

Which type of seizure results from widespread electrical activity on both sides of the brain at once?

Generalized seizure

The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use. Which medication may have caused this sensory loss?

Gentamicin (Garamycin)

What is the term for the amount of blood that is filtered in a minute?

Glomerular filtration rate

After ensuring the safety of the client, which intervention would the nurse implement for a client who is having frequent seizures?

Insert an intravenous line.

Which is an appropriate intervention for a client who is blind?

Introduce self when entering the room.

Which is likely to happen in a person who has long-term blindness?

Other senses will likely sharpen.

A nurse is preparing to give a client an injection. As the nurse begins to give the injection, the client winces and withdraws. Which factor affecting sensory response does this demonstrate?

Previous experience

Which part of the brain controls consciousness and alertness?

Reticular activating system

ICU psychosis occurs as a result of which situation?

Sensory deprivation

A nurse is caring for a client who is confused. Which would be the most appropriate way to approach bathing the client?

State, "Time for a bath."

Which describes anything that triggers a nerve receptor, such as sight, sound, taste, or smell?

Stimulus

When inserting an indwelling catheter, which level of asepsis is used?

Surgical asepsis

Which of the senses is related to gustation?

Taste

The nurse is discussing ways to treat functional incontinence with a group of older adults in a senior citizens center. Which intervention would be most appropriate for the nurse to include in the presentation?

Timed voiding

The nurse is planning to use guided imagery for a client who reports severe pain related to rheumatoid arthritis. How would the nurse perform this intervention?

Use descriptive words, music, and thoughts to elicit relaxation.

transduction

activation of nociceptors by stimuli

ways to classify pain

by origin, cause, duration, description

deep somatic

in muscle or bone

pain perception

recognizing and defining pain in cortex