NRSG 2200 - Exam #5 - Units #9 and #10
The nurse is caring for a client who works in a warehouse and has been having low-back pain. Which statement by the client indicates the need for more education regarding safe lifting? A - "I hold the boxes away from my body so I do not drop them on my feet." B - "I try to rest between periods of lifting" C - "I bend with my knees when I pick up boxes" D - "I stand with my feet apart so I have a better stance when I lift."
A - "I hold the boxes away from my body so I do not drop them on my feet."
A client who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return? A - "That is called phantom pain, and it is not unusual." B - "Oh, that is all in your mind. Just forget it." C - "Well, that is really strange. I will notify the doctor." D - "I think it might be good to refer you to a psychiatrist."
A - "That is called phantom pain, and it is not unusual."
A client who is recently divorced reports sleeping during the day and an inability to adapt to the life change. Which teaching by the nurse will promote healthy adaptation? A - "Try making a list to prioritize what needs to be done." B - "Thinking about the past will help you move forward." C - "You should get a dog so you will feel needed." D - "Save tasks until evening so you can conserve your energy."
A - "Try making a list to prioritize what needs to be done."
A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide? A - "Try to bear your weight on your hands, not your armpits." B - "Fortunately you will only need to be on crutches for a week or two." C - "I hear that a lot from clients." D - "Your armpits will grow accustomed to the weight in a dew days."
A - "Try to bear your weight on your hands, not your armpits."
The nurse is caring for a male client, age 47 years, who suffers from myasthenia gravis. He has periods of great weakness and is unable to do the things for his family that he would like to. He tells the nurse that he is not worth much these days. Knowing that sometimes clients focus on things they cannot do, which statement by the nurse might be helpful? A - "What are some of the things you do well?" B - "I'm sure that things will be better soon." C - "Some days are like that." D - "Does your family pitch in and help you?"
A - "What are some of the things you do well?"
Which nurse would be at the highest risk of causing a hazardous situation? A - A nurse who has worked 32 hours of overtime this week B - A nurse who has placed a client in the bed with three side rails up C - A nurse who is administering medications to four clients D - A nurse who is transferred to another unit to assist with care
A - A nurse who has worked 32 hours of overtime this week
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A - Adduction B - Circumduction C - Abduction D - Extension
A - Adduction
A nurse is making a home care visit to a client with a hearing deficit. What can the nurse do to facilitate communication with the client? A - Ask for permission to turn off the television set during the visit B - Reduce the time spent with the client to decrease frustration C - Use written communication rather than verbal communication D - Talk in a loud tone of voice at all times during the visit
A - Ask for permission to turn off the television set during the visit
When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall? A - Cognitive B - Affective C - Interpersonal D - Psychomotor
A - Cognitive
When the client who has been hospitalized for 8 days for skin grafting tells the nurse that he is bored, depressed, and restless, the nurse determines that the client is experiencing sensory: A - Deprivation B - Overload C - Perception D - Adaptation
A - Deprivation
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? A - Put the small nightlight in the hall and stairway B - Decorate the parents room with small rugs and wall hanging C - Locate the parent in a room near the kitchen D - Combine medications into a few pill bottles for ease of use
A - Put the small nightlight in the hall and stairway
A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client? A - Return demonstration B - Written test C - Oral test D- Stimulation
A - Return demonstration
The parents of a 10-year-old child are worried about the child's sleepwalking (somnambulism). What topic should the nurse discuss with the parents? A - Safety B - Schoolwork C - Sleep deprivation D - Privacy
A - Safety
A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? A - The clients ability to assist B - The clients body weight C - The clients cognitive status D - The clients age
A - The clients ability to assist
The home care nurse observes that a child is learning to ride a bicycle. Which would the nurse teach the child about bicycle safety? A - The importance of wearing a helmet B - The importance of using the buddy system C - The importance of using wrist guards D - The importance of wearing knee pads
A - The importance of wearing a helmet
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? A - The nurse should gently slide the client down his or her body to the floor B - The nurse should place his or her feet close together with one foot in front of the other C - The nurse should attempt to offset the momentum of the clients fall D - The nurse should grasp the gait belt and pull the clients body backward away from his or her own body
A - The nurse should gently slide the client down his or her body to the floor
A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? A - The reports provides a detailed and objective account of the circumstances before, during, and after the event. B - The incident report is reviewed by state agencies and the Occupational Safety and Health administration rather than by hospital administration C - The report becomes a confidential part of the clients health record once it is reviewed by hospital administration. D - The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed.
A - The reports provides a detailed and objective account of the circumstances before, during, and after the event.
A factory worker has a work schedule involving rotating work hours between days, evenings, and nights. The client tells the nurse he is a "morning" person and is not sleeping well when he has to work nights. The nurse recommends: A - modifying the sleep environment to stimulate quiet and darkness B - Applying for a promotion to a day shift supervisor position C - Increasing caffeine intake on days when he feels fatigues D - Obtaining a prescription for methylphenidate, a nervous system stimulant
A - modifying the sleep environment to stimulate quiet and darkness
A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply. A - "I like myself and my life." B - "What good am I?" C - "Who would want to marry me now the way I look?" D - "I'm such a horrible person." E - "I feel like I'm so ugly."
B - "What good am I?" C - "Who would want to marry me now the way I look?" D - "I'm such a horrible person." E - "I feel like I'm so ugly."
A nurse has permission from the homebound client to educate any of the family members about providing care for the client. Which family member is the most appropriate choice? A - A son who works full time and is trying to save time off for emergencies B - A brother who visits daily, does laundry, and cooks all meals for the client C - A sister who live next door to the client and telephones for updates frequently D - A daughter who is a registered nurse and lives in a different state
B - A brother who visits daily, does laundry, and cooks all meals for the client
The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated? A - Passive range of motion B - Active range of motion C - Limited range of motion D - Active assistive range of motion
B - Active range of motion
A nursing student is learning to use proper body mechanics. What is the main benefit of this action? A - Primarily protects the nurse from injury B - Acts to prevent injury to the client and/or nurse C - Body mechanics are within the nursing scope of practice D - Promotes effectiveness and efficiency of care
B - Acts to prevent injury to the client and/or nurse
The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? A - Client age B - Clients restriction C - Client food preferences D - Client restraints
B - Clients restriction
A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education? A - Gerogogical, cognitive, and adragogical B - Cognitive, affective, and psychomotor C - Cognitive, pedagogical, and psychomotor D - Gerogogical, andragogical, and pedagogical
B - Cognitive, affective, and psychomotor
A nurse has been forced to accept numerous overtime shifts over the past several months in an effort to meet personal financial obligations. The nurse now describes herself as "burned out," a condition that is comparable to what stage of anxiety? A - Alarm B - Exhaustion C - Resistance D - Recovery
B - Exhaustion
During an interview, the client states, "When my stress is really high, I have diarrhea." The physiologic response affects: A - Nutritional status B - Gastrointestinal status C - Heart rate D - Adequacy of sleep
B - Gastrointestinal status
A client is asked to graph his perception of his "real self" and his "ideal self" on a line. The real self is graphed very close to the ideal self. How would the nurse assess this client's self-esteem? A - High risk for narcissism B - High self esteem C - Very low self esteem D - High risk for altered self-esteem
B - High self esteem
Health care workers may be exposed to a common occupational injury such as: A - Carbon monoxide exposure B - Inadvertent needlestick C - Intimate partner violence (IPV) D - Sensory deprivation
B - Inadvertent needlestick
When repositioning a client, the nurse should perform what action in order to maintain the client's natural body alignment? A - Move the neck, then torso and then legs B - Logroll the client, using assistance if needed C - Reposition the lower body before the upper body D - Maximize the clients participation
B - Logroll the client, using assistance if needed
A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? A - Promoting health B - Preventing illness C - Restoring health D - Facilitating coping
B - Preventing illness
A nurse visits a client age 60 years with diabetes at home after the client's above-the-knee amputation of the left leg. The client appears disheveled and with poor hygiene and also avoids making eye contact with the nurse. What is likely to occur as a result of the client's reduced self-esteem? A - Lethargy B - Self-care deficit C - Withdrawal D - Lack of interest
B - Self-care deficit
What term best describes a person's sense of his own adequacy and worth? A - Love B - Self-esteem C - Self-actualization D - Esteem
B - Self-esteem
A client has been brought to the health care facility with accident-related injuries. During the initial interview, the client becomes agitated and upset and is unable to answer any more of the nurse's questions. What does the nurse conclude about the condition of the client? A - The clients mind is numb, and they are not able to react to further questions from the nurse B - The client mind is preparing for a fight-or-flight response as they relate the incident C - The brain is receiving less oxygen with each passing minute, which does not allow the them to speak D - The brain is sending chemicals to the bloodstream that make the client afraid of the questions
B - The client mind is preparing for a fight-or-flight response as they relate the incident
The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? A - The nurse positions a patient in a supine position prior to apply wrist restraints B - The nurse ensure that two fingers can be inserted between the restraint and patients ankle C - The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist D - The nurse ties an elbow restraint to the raised side rail of a patients bed
B - The nurse ensure that two fingers can be inserted between the restraint and patients ankle
Of the following individuals, who can best determine the experience of pain? A - The nurse caring for the client B - The person who has the pain C - The persons immediate family D - The physician diagnosing the cause
B - The person who has the pain
In an assessment for proper body alignment of a standing client, which finding is normal? A - The abdominal muscles are held downward and the buttock upward. B - The weight of the body is distributed on the soles and heels C - The line of gravity is centered over the clients toes D - The chest is downward and displaced slightly backward
B - The weight of the body is distributed on the soles and heels
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? A - Logrolling can be performed by one experienced nurse B - Use a drawsheet or a friction-reducing sheeting to facilitate smooth movement C - Logrolling will maintain straight alignment when the client is sitting in a chair D - It is acceptable to twist the client's head, but not the hips, while logrolling.
B - Use a drawsheet or a friction-reducing sheeting to facilitate smooth movement
A nurse is educating a lawn care worker on the risk of hearing loss. What might be recommended? A - "Listen to loud music with earphones while mowing." B - "Just ignore the noise, you are too young for damage." C - "Wear earplugs while using lawn equipment." D - "Clean your ears with cotton-tipped applicators daily."
C - "Wear earplugs while using lawn equipment."
The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? A - "Because you lose muscle tone with age, it hurts to walk." B - "If you recently fell, you might have a fractured hip." C - "You have lost the padding in your joints and the friction causes pain." D - "Osteoarthritis is painful and very common as your age."
C - "You have lost the padding in your joints and the friction causes pain."
A nurse always addresses clients by their preferred name when entering a client's home or room. What is the nurse facilitating by this action? A - Personal strengths B - Negative self-concept C - A sense of self and worth D - Reorientation to who they are
C - A sense of self and worth
Which statement correctly explains a person's interactions with basic human needs? A - Basic human needs and responses to stress are unaffected by sociocultural backgrounds, priorities, and past experience. B - Basic human needs and responses to stress are generalized. C - As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. D - Stress affects all people in their attainment of basic human needs in the same manner
C - As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier.
The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action? A - Roll back the stocking partially and apply padding over the tender region B - Apply the stocking, administer, analgesia to the client, and then inform the primary care provider C - Assess the client leg for signs and symptoms of deep vein thrombosis and inform the primary care provider D - Stop applying the stocking reattempt in 30 minutes
C - Assess the client leg for signs and symptoms of deep vein thrombosis and inform the primary care provider
A nurse is discussing sleep problems with a client. What type of food should the nurse recommend to promote sleep? A - One cup of peanuts B - Three glasses of red wine C - Cheese and crackers D - One cup of hot chocolate
C - Cheese and crackers
The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? A - Change the older adults routine B - Use the stairs in the new home C - Clear clutter in the walkways of the new home D - Take walks outside
C - Clear clutter in the walkways of the new home
The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. This client is most likely experiencing: A - Ineffective coping B - Activity intolerance C - Disturbed sleep pattern D - Increased sleep
C - Disturbed sleep pattern
A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. What is a practical nursing intervention for this client? A - Briefly leave the client in order to call the primary physician to assess the clients condition B - Order x-rays or CT scans for the client, as needed C - Document the incident, assessment, and interventions in the clients medical record D - Do not file an event report unless the client is seriously injured in the fall
C - Document the incident, assessment, and interventions in the clients medical record
A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain? A - Sedatives B - Narcotics C - Endorphins D - A-delta fibers
C - Endorphins
The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair? A - Infuse an intravenous fluids bolus 15 minutes before transferring the client into the chair B - Position a friction-reducing sheet under the client C - Have the client sit on the side of the bed for several minutes before moving to the chair D - Obtain a quad cane for the client to use as a transfer aid E - Wait for the primary care provider to assist the client to the chair
C - Have the client sit on the side of the bed for several minutes before moving to the chair
The nurse likes to use humor to help clients deal with pain. What guidelines should the nurse follow when using humor to foster pain relief? A - Humor should be restricted to clients who are from the nurses own cultural group B - Humor is not typically appreciated by elderly clients C - Humor should take into account the clients personality and circumstance D - Humor is most effective when clients are experiencing moderate or severe pain
C - Humor should take into account the clients personality and circumstance
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? A - I can expect to have more discomfort in the area where the cold is applied B - I should expect more drainage form the incision after the ice has been in place C - I should see less swelling and redness with the cold treatment D - My incision may bleed more when the ice is first applie
C - I should see less swelling and redness with the cold treatment
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? A - Identifies clients room number and full name B - Identifies clients last name and room number C - Identifies clients full name and date of birth D - Identifies clients date of birth and last name
C - Identifies clients full name and date of birth
What is the most common sleep disorder? A - Dyssomnia B - Parasomnia C - Insomnia D - Hypersomnia
C - Insomnia
A nurse asks an adolescent female client to describe her pain using a number between 0 and 10 where 0 means no pain and 10 means severe pain. The nurse is assessing: A - Quality of pain B - Temporal pattern of pain C - Intensity of pain D - Tolerance of pain
C - Intensity of pain
A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? A - Allow the client to use the bathroom independently B - Keep the client sedated with tranquilizers C - Involve family members in the clients care D - Maintain a high bed position so the client will not attempt to get out unassisted
C - Involve family members in the clients care
One of the most common injuries/risks associated with exercise in a healthy person is: A - Chest pain B - Decreased joint mobility C - Muscle injury D - Increased work of breathing
C - Muscle injury
The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. The nurse would recognize that this client likely has a history of what condition? A - Insomnia B - Narcolepsy C - Obstructive sleep apnea D - Somnambulism
C - Obstructive sleep apnea
When a person selects, organizes, and interprets sensory stimuli, the process is termed: A - Stimulation B - Preoccupation C - Perception D - Adaptation
C - Perception
The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include: A - Peeling paint and easy access to the backyard pool B - Household cleaners stored under the sink and hanging cords on window blinds C - Polypharamacy and use of multiple extension cords D - Risky behaviors and cyberbullying
C - Polypharamacy and use of multiple extension cords
The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate? A - Firmly grasp the clients gait belt B - Ask the client to lean against the wall while you obtain a wheelchair C - Support the clients body against yours and gently slide the client onto the floor D - Apply oxygen and wait several minutes for the weakness to pass E - Ask the client When was the last time you ate
C - Support the clients body against yours and gently slide the client onto the floor
A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? A - Ask me 3 B - Newest vital signs (NVS) C - Teach-back method D - TEACH acronym
C - Teach-back method
The nursing assistant has bathed the client who is in restraints. Upon assessing the client on hourly rounds, the nurse determines the client's restraints pose a risk for injury to the client. What assessments would lead the nurse to adjust and reapply the restraints? Select all that apply. A - One finger can be inserted between the restraint and the clients extremity B - The clients extremities are in normal anatomic positions C - The restrain is tied to the side rail of the bed D - A quick release knot is used to secure the restraint E - The restraint is tied out of the clients reach
C - The restrain is tied to the side rail of the bed A - One finger can be inserted between the restraint and the clients extremity
A community health nurse is conducting a seminar on vision self-care. What might be one topic included in the education plan? A - Use over-the-counter eye drops when necessary B - When using aerosol sprays, spray toward self C - Wear sunglasses when working outside D - Close the eyes when working with chemicals
C - Wear sunglasses when working outside
A middle-age client is reporting acute joint pain to a nurse who is assessing the client's pain in a clinic. Which question related to pain assessment should the nurse ask the client? A - "Are your family members aware of your pain?" B - "Have you thought of the effects of your condition on your family?" C - "Does your diet include red meat and poultry products?" D - "Does your pain level change after taking medications?"
D - "Does your pain level change after taking medications?"
The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate? A - "I notice that you do not have the dressing secured. Place a piece of tape on the wrap." B - "Lets see how you irrigate the wound with saline." C - "I would you like you to demonstrate how to change the dressing on your leg." D - "Tell me about what signs of infection you will report to the health care provider."
D - "Tell me about what signs of infection you will report to the health care provider."
The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response? A - "We can never be completely sure that your mother understands instructions" B - "After I demonstrate it once, your mother will be able to do it" C - "I will have you bring your mother back next week to see how things are going" D - "When 15 minutes have passed, I will ask your mother to show me how to instill the drops"
D - "When 15 minutes have passed, I will ask your mother to show me how to instill the drops"
Which of the following people has the greatest risk for accidental injury? A - An infant just learning to crawl B - An older adult who walks two miles a day C - An athlete who exercises on a regular basis D - A worker who operates industrial machines
D - A worker who operates industrial machines
A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury? A - Rub lotion on the skin of your legs and feet twice a day B - Take your insulin twice a day as we have discussed C - Remember to follow your diet so you lose weight this month D - Always test the temperature of bath water before stepping in
D - Always test the temperature of bath water before stepping in
The nurse is preparing to assess a client newly admitted to the behavioral health unit. Assessing the client's self-concept will focus on questions related to: A - History of hypertension B - Signs of infections C - Level of pain D - Body image
D - Body image
A young woman has been in an automobile crash and sustained a laceration across the left side of her face, resulting in a large scar. Which nursing diagnosis would be appropriate for this disfigurement? A - Deficient knowledge B - Anxiety C - Impaired memory D - Disturbed body image
D - Disturbed body image
When caring for a client with insomnia, the nurse would appropriately institute which intervention? A - Encourage the client to nap frequently during the day to make up for the lost sleep at night B - Advise the client to avoid food high in carbohydrates before bedtime C - Advise the client to exercise vigorously before bedtime to promote drowsiness. D - Have the client eliminate caffeine and alcohol in the evening because both are associate with disturbance in the normal sleep cycle
D - Have the client eliminate caffeine and alcohol in the evening because both are associate with disturbance in the normal sleep cycle
An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? A - Sitting him in a geriatric chair near the nurses' station B - Using the sheets to secure him snugly in his bed C - Keeping the bed in the high position D - Identifying his door with his picture and a balloon
D - Identifying his door with his picture and a balloon
Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? A - Checking to make sure fire alarms are working properly B - Preventing exposure to temperature extremes C - Screening for partner or elder abuse D - Making sure patient rooms are decluttered
D - Making sure patient rooms are decluttered
A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain? A - Allodynia B - Nociceptors C - Cutaneous D - Referred
D - Referred
Which assessment finding is consistent with the presence of pain? A - Decreased pulse B - Decreased blood pressure C - Euphoria D - Restlessness
D - Restlessness
Which term refers to our ability to execute societal expectations regarding role-specific behaviors? A - Body image B - Role conflict C - Personal identity D - Role performance
D - Role performance
The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class? A - Role modeling B - Panel discussion C - Programmed instruction D - Role-playing
D - Role-playing
What generalization can be made about safety in client care? A - Safety is an important need, but not as important as self-actualization B - Health care providers exclude safety as a client need C - Although safety is a basic human need, it is provided by self-care D - Safety is a paramount concern underlying all nursing care
D - Safety is a paramount concern underlying all nursing care
A teenage client asks herself, "Do I like who I see in the mirror?" The client is focusing on which dimension of self-perception? A - Social self B - Self knowledge C - Self expectation D - Self evaluation
D - Self evaluation
An example of a long-term coping strategy is: A - Indulging in a rich desert after a stressful day B - Crying to release tension after a stressful event C - Taking a stick and banging in on a tree D - Walking briskly three times a week for 20 minutes
D - Walking briskly three times a week for 20 minutes
The nurse is assessing clients for risk factors in the workplace. Which clients would be at risk for injury due to the environment of the workplace? Select all that apply. A - Owner of a fitness center who teaches one yoga class a day B - Medical records technician who works in a doctors office C - Worker who operates equipment in an automobile assembly plant D - Gardener who mows and places fertilizer on lawns E - Nursing assistant who lifts clients in a nursing home
E - Nursing assistant who lifts clients in a nursing home D - Gardener who mows and places fertilizer on lawns C - Worker who operates equipment in an automobile assembly plant
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: A - Foot drop B - Blood pressure changes C - Pooling of blood D - Decubitus ulcers
A - Foot drop
An older adult woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury? A - Fractured hip B - Fractured Ulna C - Thigh contusion D - Lacerated hip
A - Fractured hip
When asking an older adult client about abdominal pain, the client reports, "I do not want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action? A - Gently mention that the client appears to be experiencing pain that can be treated B - Document the client's statement, and do nothing further C - Confirm that age is the reason for many types of pain D - Remind the client that pain can be tolerated instead of using addictive pain medication
A - Gently mention that the client appears to be experiencing pain that can be treated
The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system? A - Heart rate of 102 BPM B - Cool, clammy skin C - Increased bowel sounds D - Blood sugar of 65 mg/dL (3.61 mmol/L)
A - Heart rate of 102 BPM
A nurse is caring for a client diagnosed with sleep apnea. Which nursing diagnosis should the nurse include in her nursing care plan? A - Impaired gas exchange B - Impaired bed mobility C - Risk for injury D - Relocation stress syndrome
A - Impaired gas exchange
The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action? A - Obtain a medical interpreter B - Use a translating application for cellular phone to aid in communication C - Have a family members translate D - Request other health care providers who speak the clients language to care for the client
A - Obtain a medical interpreter
The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? A - Privacy B - Safety C - Confidentiality D - Nurse-client relationship
B - Safety
What is the leading cause of injury-related deaths in adults 65 and older? A - Falls B - Alcoholism C - Motor vehicle accidents D - Violence
A - Falls
Which response from the client enables the nurse to determine the effectiveness of a recent medication teaching session for an older adult client who is diagnosed with tuberculosis (TB)? A - " I will be taking the TB medication for at least 6 months, because it take a long time to kill the TB germs." B - "It is okay to skip some doses if I don't feel well or sick to my stomach." C - "I can't remember when I have to take my medications, so I have my son come and give me my pills." D - "If I stop coughing after 3 months, I can stop taking my TB medication because that means I no longer have the germ in my system."
A - " I will be taking the TB medication for at least 6 months, because it take a long time to kill the TB germs."
The nurse is readmitting a client who was discharged 1 week ago with complications from diabetes mellitus. The client states, "I really did not understand what I was supposed to do to care for myself from those papers that I was sent home with." What question will the nurse ask to promote the client's self-esteem? A - "How do you learn best and what can we do to provide you with that information?" B - "What was so difficult about the discharge instructions?' C - "Do you have a problem with reading?" D - "You understand that if you are not able to care for yourself, will you'll continue to be admitted?"
A - "How do you learn best and what can we do to provide you with that information?"
A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the clients risk for a fall? (select all that apply) A - Orient the client to the room and environment upon admission B - Provider the client with a bedpan to reduce ambulating to the restroom C - Administer pain medications sparingly in order to minimize any cognitive side effects D - Place the client in a shared room with a client how is stable and oriented E - Ensure the call light and personal belongings are within reach
A - Orient the client to the room and environment upon admission E - Ensure the call light and personal belongings are within reach
What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital? A - Orienting clients to the surroundings decreases the potential for injury B - It is part of the routine and is included on the admission checklist C - It allows time for the healthcare provider to write admission orders D - It is hospital policy
A - Orienting clients to the surroundings decreases the potential for injury
What nursing diagnosis would you give a patient who shows the following symptoms when moving: *client reports shortness of breath when getting up to the bathroom *increase in heart rate and respiratory rate when up and moving *decrease in blood pressure
Activity intolerance
Which strategy should the nurse use when providing education to the older adult client? A - Teach from books only and remain calm B - Remain calm and conduct the teachings session in a quiet environment C - Teach in a monotone voice in a quiet environment D - Avoid the use of colorful materials and keep the session short
B - Remain calm and conduct the teachings session in a quiet environment
The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than 24 hours. Which priority problem will the nurse identify? A - Impaired physical mobility B - Risk for impaired skin integrity C - Impaired transfer ability D - Risk for disuse syndrome
B - Risk for impaired skin integrity
An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate? A - "Drink a glass of water before attempting to stand to promote circulation." B - "Move slowly and sit on the edge of the bed before transferring to the chair." C - "Place feet firmly on the floor when rising to maintain balance." D - "Place your head lower than your heat if you begin to feel dizzy."
B - "Move slowly and sit on the edge of the bed before transferring to the chair."
A middle-age adult discusses with the nurse the loss of his job due to frequent illness. The nurse recognizes the client's loss of his income as which of the following? A - Adaptation B - A stressor C - A coping mechanism D - Homeostasis
B - A stressor
The nurse is providing education for a client who will be providing self-care at home. The client states, "I just do not think I can do all of this. It is too much to learn." What is the best response by the nurse? A - "I understand that you are frustrated and a bit overwhelmed with all of the information, but if you do not learn how to do it, who will take care of you?" B - "I understand that you are frustrated and a bit overwhelmed with all of the information, but it is not difficult information, this is why I am providing education." C - "I understand that you feel overwhelmed with all of the information. Tell me what I can do to help." D - "I understand that you feel overwhelmed with all of the information, but you will be just fine."
C - "I understand that you feel overwhelmed with all of the information. Tell me what I can do to help."
A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. A - The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes B - The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions C - The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions D - The nurse includes an 8 year old patient in the teaching plan for managing cystic fibrosis E - The nurse demonstrated how to use an inhaler to an 11 year old male patient and includes his mother in the session to reinforce the teaching F - The nurse continues a teaching session os STIs for a sexually active male adolescent despite his protest that "I've head enough already!"
E - The nurse demonstrated how to use an inhaler to an 11 year old male patient and includes his mother in the session to reinforce the teaching D - The nurse includes an 8 year old patient in the teaching plan for managing cystic fibrosis C - The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions
A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A - Stop performing the exercises B - Decrease the number of repetitions performed C - Reevaluate the nursing care plan D - Move to the patients other side to perform exercises E - Encourage the patient to finish the exercises and then rest F - Assess the patient for other symptoms
F - Assess the patient for other symptoms C - Reevaluate the nursing care plan A - Stop performing the exercises
