Chapter 31,18,19,20,28

In assessing the skin condition of an elderly patient, the nurse notes that, over the sacral area, there is a 2-cm 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

2-cm 3-cm reddened area on sacrum with open center. Does not blanch.

The nurse attempts to help an 86 year old patient describe his pain because the nurse is aware the elderly do not express pain because they:(Select all that apply.)

Believe pain is a natural consequence to aging. Are reluctant to bother the nursing staff. Have been culturally trained not to complain.

An elderly patient who is unable to get out of bed complains that the room is too cold because of the air conditioning and asks the nurse to open the window. The nurses best reply is:

Ill adjust the thermostat in your room and get a blanket for you.

The nurse performing a focused assessment on pain will assess: (Select all that apply.)

History of pain. Verbal indicators. Psychological factors. Contributing factors.

A nurse admitting a 76-year-old patient to the unit carefully documents the appearance of a stage III pressure ulcer and informs the charge nurse because:

Medicare will reimburse the facility if the ulcer advances.

A natural supplement that can enhance sleep for many people is:

Melatonin

The nurse assessing for a pressure ulcer in a patient with darkly pigmented skin should:

Look for a purple hue under natural light.

A nurse caring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by:

Placing a towel between the pack and the skin.

Which of the following are main functions of the skin? (Select all that apply.)

Protection Excretion Sensation Secretion

The nurse assisting a weak patient from a bed to the wheelchair to go to physical therapy would:

Seat the patient on the side of the bed with feet touching the floor.

A patient with insulin-dependent diabetes has a below-the-knee amputation on the right leg. What modification of his personal care is noted as most important?

The patients left foot should be soaked and gently dried, but his toenails should not be cut.

The patient most at risk for a pressure ulcer would be:

a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed.

A patient who is weak from inactivity following a car accident benefits most if the nurse provides for:

active ROM exercises to arms and legs several times a day.

A diabetic patient has chronic peripheral vascular disease, which results in edema and poor circulation to her feet. She constantly complains of cold legs. The best nursing action is to provide:

additional blankets and encourage the use of warm bed socks.

A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should:

assess the patients response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding.

When the nurse is assisting a male patient to shave his face, it is most important for her to:

check whether a safety razor can be used or whether it is contraindicated.

One of the facilitys unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to:

cut the nail straight across with a nail clipper.

The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:

infection with bacteria or viruses that may affect the person systemically.

An elderly patient is discharged home after hip surgery. The statement that indicates a family member understands discharge safety instructions given by the nurse is, I will:

install grab bars in the bathroom for both the toilet and bathtub.

A nurse is instructing one of the facilitys unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, I will:

lift using my back muscles.

The best way to maintain safety measures relative to helping a patient get into bed is to:

make sure that the bed wheels are locked.

An appropriate environmental nursing intervention for a patient with respiratory congestion is to:

moisten the respiratory passages with the use of an air humidifier.

The nurse caring for a patient who is not taking any food or fluids by mouth because he is unconscious is aware that the patient:

needs to have his mouth swabbed to moisten and remove secretions every 4 hours.

When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to:

offer additional fluids to replace those lost through normal cooling.

The nurse asseses a patients sleep for NREM sleep because this sleep has the characteristics of

offering the most

A 20-year-old male patient is admitted after an auto accident. He has blood and dirt matted in his hair. The nurse should:

remove tangles by using alcohol or water on small sections of hair, holding the hair between the scalp and the area the nurse is brushing or combing.

A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words and is unsteady when ambulating. The nurse should:

remove the patch and wipe off the skin

The patient complains of an odor in his room that smells like something is rotting. The nurse makes an assessment of the room and:

removes an old flower arrangement.

Providing oral care to a patient who has dentures includes:

removing, cleaning, and storing the dentures in a labeled container at bedtime.

A patient complains of not being able to sleep because of the noise in the hall at night. The nurse should:

request that co-workers limit hallway conversations.

When providing perineal care for an uncircumcised male patient, the nurse:

retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure.

The nurse shampooing the hair of an African American takes into consideration that the hair:

should only be washed every 7 to 10 days.

A sleeping patient has periodic pauses in breathing, then starts to breathe again. The nurse recognizes this sleep pattern is consistent with:

sleep apnea.

A nurse is ambulating an unsteady patient from the bed to a chair in the patients home. To do so safely, the nurse applies a gait belt and:

slides his hand from the bottom under the gait belt at the middle of the patients back.

A usual routine for providing nail care to a patient includes:

soaking the nails in warm soapy water to soften before cleaning under the nail edge with an orangewood stick.

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this applience helps reduce pain by:

supporting surface and internal tissue

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to:

use a lens suction cup to remove the lens.

The culturally sensitive nurse caring for a Muslim woman who has noticeable body odor as well as abundant underarm hair should:

use soap and water under the arms.

To provide correct body alignment for a physically immobile patient in bed in the supine position, the nurse:

uses a footboard or places high-top sneakers on the patients feet to maintain dorsiflexion.

A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse:

uses logrolling to accomplish position changes from side to side.

A stage III pressure ulcer is indicated by: (Select all that apply.)

full-thickness skin loss. drainage from the ulcer. damaged subcutaneous tissue.

The nurse in a long-term facility who is making a fall assessment would identify the person most at risk for a fall to be a resident who:

had a stroke with right-sided weakness 2 weeks ago and is confused.

The changes in the integumentary system that are part of the normal aging process are: (Select all that apply.)

hair becomes thin and grows more slowly. skin is more fragile because of loss of collagen fibers. skin wrinkles and sags.

.It is most important for the nurse to write specific personal care plan modifications for the patient who:

has an artificial eye and poor vision in the other.

A physician orders the nurse to place a patient in Fowlers position. The nurse should elevate the head of the patients bed _____ degrees.

60 to 90

The patient for whom passive range-of-motion exercises would be most beneficial would be the:

66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CVA).

A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?

A rolled washcloth in the palm of her left hand or a hand splint

The nurse takes into consideration The Joint Commission (TJC) standards for pain assessment and treatment include:

All patients have the right to appropriate assessment of pain.

The suggestion by the nurse which is most helpful to a patient who complains of chronically not feeling rested after sleep would be:

Avoid going to bed hungry or overly full.

As the nurse is helping an 85-year-old man to stand and ambulate, he complains that he feels that he has lost all of his strength in the last several years and cannot do the things he could do when he was 80. The nurses most informative response would be:

As we age our muscle cells are lost and replaced by fat, which leads to loss of strength.

A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to:

Assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt.

The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is:

Back injuries from lifting and twisting.

A nurse explains that endorphins are capable of reducing pain:

By attaching to opioid receptors.

A patient experiencing discomfort because of severe arthritis would be described as having ___ pain

Chronic

A nurse is assessing the status of a patient who is sleeping. Which assessment data indicate that the patient is most likely in stage 3 of nonrapid eye movement (NREM) sleep?

Decreased respirations, slow heart rate

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak?

Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary.

The nurse recommends that normal sleep patterns can best be acquired by suggesting to the patient that they:

Exercise in the mornings.

The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPNs most accurate information relative to moving patients is:

Get one other aide to help and use the mechanical lift when you get Mr. A out of bed in the morning. He is heavy and doesn't assist at all.

The most helpful intervention by the nurse for a hospitalized child who is having difficulty falling asleep would be:

Having the parents bring a favorite blanket or pillow from home.

Because the elderly patient lies curled up in a side-lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the:

Ilium.

A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route. It is most important to monitor this patient for which adverse drug effects?

Hypoventilation

A nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage _____ pressure ulcer.

I

A patient is receiving an ice massage for relief of muscle spasms in the neck. The patient complains that the ice is making the pain worse. Most helpful response from the nurse would be:

I will stop these cold applications. Not everyone is helped by them.

The nurse is aware that the new order for indomethacin (Indocin) involves the administration of a:

Nonsteroidal anti-inflammatory drug.

Complications from incorrect alignment and positioning include which of the following? (Select all that apply.)

Pressure ulcers Contractures Fluid in the lungs

To perform oral care for an unconscious patient, the nurse takes which action first?

Raise the bed to a comfortable working height and position the patient in a flat side-lying position.

A patient experiencing pain states that guided imagery has made the pain more manageable in the past. To assist this patient, the nurse should:

Read from a script that helps the patient visualize a restful place.

The nurse takes into consideration that when the patient has an order for a patient controlled analgesia (PCA) the pump will be programmed by the:

Registered nurse

A nurse evaluating the effectiveness of an Aquamatic K-pad for the leg is aware that the patient who has the least risk for burn injury from this device would be the patient with:

Severely sprained ankle

A patient who has difficulty falling asleep at night because of anxiety over family problems asks if he should start taking sedative pills from the pharmacy to sleep better. The best advice to give this patient is that these pills can be used for:

Short periods of time, but it is best to check with the physician first.

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? (Select all that apply.)

Summon at least one other person to assist. Obtain a lift sheet. Place the patient flat on her back.

A nurse is instructing a patient about relaxation techniques for pain management. The patient should:

Tense and relax individual muscle groups, starting with the toes and feet.

The nurse outlines the four phases of nociceptive pain as: (Select all that apply.)

Transduction Transmission Modulation Perception

A patient with an epidural catheter needs to have the dressing at the insertion site changed. When cleaning the insertion site with povidone-iodine swabs, the nurse should:

Use a circular motion working from the insertion site outward.

When instructing a nursing assistant about hygiene needs of a frail elderly patient, the nurse correctly educates the nursing assistant to:

Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling.

A relative complains that an elderly patient takes frequent naps during the day and awakens frequently during the night, and wants to know if this is normal. The nurse explains that an older adult:

Will awaken more often during the night, but may nap more often during the day.

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have:

a deep pink area of unblanchable skin.

An agitated resident who is seated in his wheelchair calls the nurse because the bed linens are smoldering. After moving the patient to the hall, the nurse should:

activate the fire alarm system immediately.

A patient who has a dry, itchy dermatitis will most likely benefit from:

an oatmeal or starch therapeutic bath with tepid water.

A patient who has right-sided weakness following a stroke is admitted to a long-term care facility and exhibits increasing wandering and inability for self-care. To protect the patient from the most frequent cause of injury among the elderly, the nurses most efficient intervention would be:

apply a personal alarm.

A patient is beginning treatment for pain with a transcutaneous electrical nerve stimulator (TENS) unit. The nurse will initaly

apply conductive jelly to un-coated electrodes.

There is evidence that a resident in a home care environment might have accidentally ingested gasoline left by the gardeners. The nurse should first:

call the poison control center and describe the situation.

An example of the principles of good body mechanics applied to patient care occurs when the nurse:

keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement.

The nurse appreciates the principal advantage in using patient-controlled analgesia (PCA) is that it:

reduces patient anxiety about pain by giving the patient more control in its management.

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the:

patient will shower or tub bathe with assistance twice a week.

An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to:

place the patient on her stomach (prone position) using a small pillow below her diaphragm.

The nurse caring for a patient with a nursing diagnosis of Injury, risk for, related to right-sided weakness as evidenced by unsteady gait, would accommodate the patient by:

placing the wheelchair on the left side of the patient before transfer.

A nurse is instructing a nursing student regarding prevention of pressure ulcers. The nurse would recognize further instruction is warranted when the nursing student states, I will:

position the patient directly on the trochanter.

A patient has left-sided paralysis following a right-sided cerebrovascular accident (CVA). After completing a bed bath, the nurse should begin to change the sheets by:

positioning the patient in a side-lying position on his left side with the near side rails raised.

A patient has a quarter-sized blackened eschar on both heels surrounded by a 1- to 2-cm indurated reddened area. The nurse is aware that these lesions are:

pressure ulcers that cannot be accurately staged because of the eschar.

When the post-stroke patient complains to the nurse, I dont see why you are wasting your time doing the passive range-of-motion exercises on my legs, the nurses most informative response would be based on the knowledge that the exercises:

prevent contractures of the hips.

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to:

prevent fluids from collecting in the patients mouth and being aspirated.

To place a patient in the Sims or lateral-lying position, the nurse would initially:

raise the bed to a waist-high working level.

When the nurse is making an occupied bed, back safety indicates that the nurse should initially:

raise the bed to the proper working height before starting.

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should:

reassess the area after 30 to 45 minutes for reactive hyperemia.

While the nurse is assisting a patient to ambulate, the patient suddenly says, Im dizzy. I cant stand up. As the patient begins to fall, the nurse should:

step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor.

The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when:

the patient is pulled up in bed without being lifted.

An important factor to consider when assessing the hygiene needs of a patient is that:

the patient may not have the same hygiene practices as the nurse.

A nurse is preparing to give a complete bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse:

washes each eye with a fresh area of the washcloth before washing the rest of the patients face.

When caring for a patient with acute radiation sickness (ARS) after an accident at an atomic power plant, the nurse should:

wear a paper gown and boots, gloves, and a mask.