Test 4 Professional Nursing

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? [select all that apply]

"Have your working hours changes recently?" / "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" / "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" / "Tell me about any personal stress you are experiencing?"

A nurse is caring for a client who is 3 days post-op following a below the knee amputation as a result of a motor vehicle crash. Which of the following statements indicates that the client has a distorted body image?

"I don't even want to look at my leg. You can check the dressing."

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I take the batteries out of my hearing aids when I take them off at night"

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept?

"I'll never be able to care for this at home. Can't you just send a nurse to the house?"

A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I'll take a short nap whenever I feel a little sleepy"

A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery stating, "my body is so different now." Which of the following responses should the nurse make?

"I'm interested in finding out more about how your body feels to you"

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make?

"It sounds like you are concerned about sexual functioning. Let's discuss your concerns"

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner says, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? [select all that apply]

"Would you like me to contact the chaplain to come and speak with you?" / "You know, it is quite normal to feel anger toward your loved one at this time" / "Tell me more about how you are feeling"

A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "how could you possibly understand what I am going through?" Which of the following responses should the nurse make?

"You are right, I cannot really understand. Perhaps you would like to tell me more about what you are feeling"

A nurse is caring for a group of clients on a med-surg unit. Which of the following clients are at increased risk for body-image disturbances? [select all that apply]

A client who had a mastectomy / A client who had a left above the knee amputation / A client who had a stroke with right-sided hemiplegia

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?

Alarm stage

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? [select all that apply]

Allow the client to provide input in the treatment plan / Assist the client with time management, and address the client's priorities / Encourage the client in the expression of feelings and concerns

A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first?

Allow the client to take a bath in the evening

A nurse is about to perform postmortem care on a client. The family wishes to view the body. Which of the following actions should the nurse take? [select all that apply]

Apply fresh linens and place a clean gown on the body / remove all equipment from the bedside / dim the lights in the room

Interventions for improving taste

Assess for sores in the mouth; monitor dietary intake; provide oral hygiene; allow client to select favorite foods; encourage spices, salt substitutes, and seasonings

A nurse is caring for a client who has stage IV lung cancer and is 3 days post-op following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler Ross model, which stage of grief is the client experiencing?

Bargaining

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

Check to see whether the catheter is patent

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Clamp the enema tubing

Interventions to improve visual senses

Clean glasses; arrange family pictures in room; offer colorful clothing; hang artwork on wall

A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?

Convening a family meeting

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? [select all that apply]

Decrease and avoid caffeine / Avoid drinking alcohol

Interventions for confused clients

Decrease anxiety; maintain safety; promote orientation; provide continuity of care; simplify communication

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?

Decreased muscle tone

Interventions for communicating with the visually impaired

Describe room layout; explain unfamiliar sounds; speak before you touch the client; let the client know when you are leaving the room; introduce yourself when entering the room; call the client by name

A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?

Discard the first voiding

The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? [select all that apply]

Explain things before performing them; speak slowly, articulating clearly; validate understanding of verbal communication; ask whether he has a "good ear"

A nurse is reviewing factors that increase the risk of a urinary tract infection (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? [select all that apply]

Frequent sexual intercourse / Location of urethra closer to the anus / Frequent catheterization

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client is currently taking should alert the nurse to a further risk for ototoxicity? [select all that apply]

Furosemide / Ibuprofen

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? [select all that apply]

Have the client record urination times / Gradually increase the urination intervals / Remind the client to hold urine until the next scheduled urination time

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? [select all that apply]

Hypotension / elevated temperature / poor skin turgor

A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? [select all that apply]

Make sure only one person speaks at a time / Allow plenty of time for the client to respond / Use brief sentences with simple words

The nurse is caring for a client who says "food just doesn't taste good anymore." What priority action should the nurse take?

Monitor dietary intake

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?

One medium apple with skin

Interventions to improve smelling and tactile senses

Place fresh fruit nearby; place fresh flowers nearby; hold a client's hand when giving bad news; use aromatherapy

Interventions to improve auditory senses

Place hearing aids daily; confirm ears are clean; check hearing aids batteries regularly; place in quiet area; increase audio on television

Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay?

Place her bed in lowest position

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? [select all that apply]

Practice muscle relaxation techniques / Exercise each morning / Alter the sleep environment for comfort / Limit fluid intake at least 2 hours before bedtime

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement?

Provide a private room, and limit stimulation

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? [select all that apply]

REM sleep provides cognitive restoration / It is difficult to awaken a person in REM sleep / Vivid dreams are common during REM sleep

Interventions for decreasing sensory overload

Reduce noxious odors promptly; minimize lighting; minimize nighttime interruptions; only use the television when the client is interested; lower voice and alarm sounds

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem?

Role conflict

Which factors can impact a person's sensory alteration? [select all that apply]

Sensory deprivation Sensory overload Sensory deficit

The nurse is caring for a client who has been in the intensive care unit for a week. The nurse notes that the client is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes?

Sensory overload

Interventions for communicating with the hearing impaired

Speak to the client's "stronger" ear; don't speak while eating or chewing gum; don't shout; validate understanding; use visual cues; speak slowly and articulate clearly; use pen and paper when needed

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

The client's sense of loss can be lessened through retaining control of some areas of life

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

The specimen cannot be contaminated with urine

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? [select all that apply]

Warm the enema solution prior to instillation / Position the client on the left side with the right leg flexed forward / Lubricate the rectal tube or nozzle

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? [select all that apply]

Weber test showing lateralization to the right ear / Rinne test showing less time for air and bone conduction