Nursing Concepts Week 5
What is the term for a coping mechanism that involves ways in which individuals see their symptoms and take action?
Illness behavior
During a preschool screening, the parent of a 3-year-old child asks the nurse how many hours of sleep the child requires each night. Which response by the nurse is the most appropriate?
12-14 Growing children require more sleep than adults. The 3-year-old child requires 12 to 14 hr of sleep each night. Infants get 14 to 15 hr of sleep in 24 hr. Adolescents require 9 to 10 hr of sleep each night. Adults need 7 to 9 hr of sleep each night.
The nurse is caring for an older adult client who exhibits sundown syndrome. Which assessment findings would the nurse expect for this client to exhibit while providing care in the lateafternoon?
Agitation A client with sundown syndrome would exhibit agitation, anxiety, aggression, and delusions. Eupnea, sleepiness, and tachycardia are not expected assessment findings for clients with sundown syndrome.
A nurse working in the sleep lab teaches her clients the clinical changes of NREM sleep. Which assessment findings represent the changes in Stage II of NREM sleep? (Select all that apply)
Body temperature decreases Pulse rate slows Respiratory rate slow During Stage II of NREM sleep, the client will experience a decrease in pulse, respiratory rate, and body temperature. The client would not experience an increase in cardiac output or skeletal muscle tension.
What are the characteristics of sleep? (Select all that apply.)
Changes in the body's physiological processes Variable levels of consciousness Minimal physical activity A decrease in responsiveness to external stimuli
A client asks the home care nurse about the difference between acute and chronic illness. What information can the nurse give the client about the characteristics of chronic illness? (Select all that apply.)
Chronic illness has a slow onset. Chronic illness usually lasts six months or more. Chronic illness can remain for life. Chronic illness can have remissions. Chronic illness can have both remissions and exacerbations. It usually lasts six months or more, and can remain for life. It has a slow onset.
The client is reporting difficulty sleeping. Which assessment findings may be causing this client's sleeping difficulties? (Select all that apply.)
Cigarette smoking A cup of coffee after dinner each night Several glasses of wine in the evening Assessment findings that may be contributing to the client's sleeping difficulties include evening caffeine and alcohol intake and cigarette smoking. Recent weight loss contributes to an improved sleep pattern. Financial instability, not stability, can cause sleep disturbances.
After collecting detailed assessment data, a nurse verbally summarizes the data aloud. What are the reasons that the nurse takes this approach? (Select all that apply.)
Client has an opportunity to validate the data Client becomes more aware of the need for behavioral change The nurse verbally summarizes to give the client an opportunity to validate the data. The client also becomes more aware of the need for behavioral change. The approach does not concern health literacy, illness behavior, or social support.
What are some internal variables that influence an individual's health? (Select all that apply.)
Culture Sex Genetic makeup Age
A client complains to the nurse,"I feel that there is nothing that I can control about my health." The empathetic nurse realizes that the client is totally focused on internal variables. For which factors is the client's complaint correct? (Select all that apply.)
Culture Age Genes Sex The client is correct that some health-related factors cannot be controlled: genes, age, sex, and culture. However, nutrition is an external variable, and the client can control that factor.
A client told the nurse doing a health history that she could not provide information about a family history of diseases because she had been adopted immediately after birth. No family health information was provided. For which diseases would having that information beuseful? (Select all that apply.)
Diabetes Breast cancer Ovarian cancer There is a genetic component to susceptibility to diabetes, breast cancer, and ovarian cancer. Influenza is an illness, not a disease, and does not have a genetic component. TB does not have a genetic component.
What is true regarding the oral health of the older adult?
Dry mouth may occur due to a decrease in saliva production.
Which phase of the nursing process is documented by the statement "The client has attended a yoga class once a week".
Evaluation
A nurse wrote about a client's progress, "Even though the client started recording everything she ate in a food diary, the client's weight increased by 2 lbs. this week." Which phase of the nursing process does this statement exemplify?
Evaluation A statement about the client's outcome, even if the goal is not reached, is part of the evaluation phase. The other phases precede it.
Which factor negatively affects the ability to sleep?
Exercise late in the day
A nurse is caring for a client diagnosed with hypertension. The client's healthcare provider suggests the client begin a regular exercise schedule. The client asks the nurse, "How will exercise benefit my brain? The doctor said that exercise benefits the brain but I don't see how it can." What is the nurse's best response?
Exercise leads to improved problem solving. With exercise, increased toxin elimination occurs with improved ventilation and increased oxygenation to the brain. This leads to improved problem solving. The other answer choices are incorrect.
A college health clinic nurse is working with a homesick freshman from a large extended family. The client has come into the clinic several times in the first semester with injuries. Which characteristic of the client's developmental level is a possible factor?
Exhibition of risk-taking behavior Adolescents exhibit risk-taking behavior. Infants lack defenses against disease. Toddlers have an increased number of falls. Older adults have declining physical abilities.
The nurse is caring for an adult client who is diagnosed with insomnia. Which assessment finding supports this diagnosis?
Fatigued feeling during sedentary activities The client experiencing insomnia would exhibit fatigue during sedentary activities. Sleeping 8 hours each night is an appropriate amount of sleep and does not support the diagnosis. Decreasedconcentration, not increased concentration, would support this diagnosis. Increased irritability, not decreased irritability, would also be an assessment finding to support this diagnosis.
What are the basic aspects of wellness? (Select all that apply.)
Having an ultimate goal Self-responsibility Daily decision making
A Chamber of Commerce wants to partner their business members with local government to produce visible efforts to improve health. At a Chamber meeting, what kind of health promotion activities could the members propose? (Select all that apply.)
Health fairs Recycling efforts Immunization awareness efforts Fitness programs Health promotion activities could include health fairs, fitness programs, recycling efforts, and immunization awareness efforts. Methadone clinics are a form of treatment, not health promotion.
The nurse is reviewing a list of the client's medications. The nurse assesses the medications and identifies medication classes that can affect sleep. The nurse is concerned about which medications? (Select all that apply.)
Hypnotics Beta blockers Narcotics Antidepressants It is important for the nurse to consider the effect of medications on a client's sleep pattern. Hypnotics interfere with deep sleep and suppress REM sleep. Beta blockers cause insomnia and nightmares. Narcotics suppress REM sleep, causing frequent awakenings and drowsiness. Antidepressants suppress REM sleep. Nonsteroidal anti-inflammatory drugs have no effect on sleep.
A nursing student is having difficulty differentiating between the appropriate use of the word illness and the word disease. Which statement is confirmation of that difficulty?
Illness shortens the normal life span. Disease, not illness, shortens the normal life span. Disease is an alteration in body function and its symptoms can disappear. An illness can be either serious or trivial.
The nurse is providing care to a client at a sleep disorder clinic. Which assessment finding does the nurse expect during REM sleep?
Increase in gastric acid During REM sleep, the nurse would expect the client to have an increase in gastric acid. A decrease in heart rate and respiratory rate is also expected. An increase, not a decrease, in eye movement is expected during REM sleep.
An older adult client has been taking care of a grandchild with severe autism spectrum disorder. The home care nurse recognizes that this condition has caused the adult client prolonged emotional distress. What effects in the grandparent would concern the nurse? (Select all that apply.)
Increased susceptibility to disease Altered endocrine levels Increased susceptibility to infections Alterations in the central nervous system Prolonged emotional distress can cause increased susceptibility to disease and infections, as well as alterations in the central nervous system and endocrine levels. Prolonged emotional distress increases, not decreases, the possibility of premature death.
The nurse is discussing with a client the effect of lifestyle factors on sleep. Which activities should the nurse include as factors that negatively influence sleep? (Select all that apply.)
Irregular work schedule Evening exercise Factors that negatively impact sleep include evening exercise and an irregular work schedule. Morning exercise, relaxation, and regular nighttime schedule are known to enhance sleep.
A nurse is caring for a client who delivered a healthy baby boy by cesarean section (C-section) 24 hours ago. The nurse notes that the client correctly uses her arms to help transfer in and out of bed. Which type of exercise is the client demonstrating when performing this activity?
Isotonic
Which type of exercise is also known as dynamic exercise?
Isotonic
A nurse is caring for a client who is postoperative from an open appendectomy. The client uses an overhead trapeze bar to transfer position in bed. Which type of exercise is demonstrated with this action?
Isotonic The client who uses an overhead trapeze bar to aid in transfer is demonstrating isotonic activity. Isometric activity is when the joint doesn't move but the muscle contracts "wall sits," for example). Isokinetic exercise is when the muscle contracts against resistance.
A clinical specialist in diabetes care and a nutritionist are discussing the 8-week workshop they facilitate for groups of newly diagnosed diabetics. Which type of health promotion program are they coordinating?
Lifestyle changes The workshop is aimed at producing lifestyle and behavior changes. Because the workshop audience members have a disease, the workshop is not about information, assessment of wellness, or environmental control.
A client was recently diagnosed with type 2 diabetes. This diagnosis led to changes in diet, recommended activity level, and frequent glucose monitoring during waking hours. What kind of changes is the client experiencing?
Lifestyle changes The client's disease requires lifestyle changes: altered diet and activity level, and frequent testing. It is not a matter of emotional, body image, or self-concept changes.
The nurse is caring for a preschool-age client who is experiencing nightmares. Which suggestion by the nurse is the most appropriate?
Limit television time The preschool-age client who is experiencing nightmares would benefit from limiting television time. Television time is associated with nightmares in the preschool-age client. Encouraging nighttime routines and increasing physical activity will promote sleep, but not decrease nightmares. It is outside the scope of nursing practice to prescribe medication to a client.
What are some considerations to take into account when disseminating health information? (Select all that apply.)
Literacy level Age group Culture
Which type of exercise is particularly helpful for clients with chronic obstructive pulmonary disease (COPD)?
Lower body
The nurse is administering medications to a group of clients on a medical-surgical unit. Which medication is most likely to cause a client to experience frequent awakenings during the nighttimehours?
Morphine Narcotics, such as morphine, are known to cause frequent awakenings and drowsiness. The client receiving Morphine would most likely experience frequent awakenings. Propranolol, Trazodone, and Tylenol are not known to cause this phenomenon.
What are the small protuberances on the tongue that provide surface texture to assist in licking and moving food?
Papillae
Which measurement is part of a lifestyle assessment?
Physical activity
Which part of the tooth contains the blood vessels and nerves?
Pulp
Which statement regarding the benefits of exercise for the respiratory system is true?
Regular exercise prevents secretion pooling in the lungs, decreasing risk of respiratory infection.
Which nerve fiber is involved in the sleep-wake cycle?
Reticular activating system
Which exercises are classified as aerobic? (Select all that apply.)
Running Hiking Swimming
A nurse is caring for an older adult who complains of dry mouth. The client states, "Food just doesn't taste the same anymore." The nurse understands that the client's dry mouth may be the cause of the client's altered taste. Which statement is true regarding saliva and taste?
Saliva liquefies food chemicals so that they can be tasted, so a decrease in saliva will decrease taste. Saliva liquefies food chemicals so that they can be tasted, so a decrease in saliva will decrease taste. Saliva does not increase the function of the taste buds. Saliva is produced by the salivaryglands, not the tongue. Saliva chemically breaks down food; teeth mechanically break down food.
A client has a long list of health protection needs. A parish nurse can provide some of the education but thinks that the client would benefit greatly from collaborative interventions. Which of the following interventions is collaborative?
Scheduling a visit with a nutritionist Scheduling a visit with a nutritionist is a collaborative intervention. The other interventions are independent interventions.
The nurse enters the room of a sleeping client whose eyes are rolling from side to side and whose respiratory rate and heart rate have decreased. The client is easily aroused and states, "I wasn't asleep." This client was in which stage of NREM sleep?
Stage I Stage I is the stage of light sleep in which the client is easily aroused, respiratory rate and heart rate decrease slightly, and eyes roll from side to side. Stage II is the stage of light sleep in which body processes slow down and eyes are still. Stage III is the stage of deep sleep in which it is difficult to arouse the client, muscles are relaxed, and reflexes are diminished. Stage IV is the stage of deep sleep that differs from Stage III in the number of delta waves produced.
The nurse is providing care to a client participating in a sleep study. The nurse documents eye rolling from side to side, decreased respiratory and heart rate, and being able to easily arouse the client. Which stage of NREM sleep is the client experiencing?
Stage I This client is exhibiting assessment findings that occur in Stage I of NREM sleep. The other stages will not exhibit these symptoms.
A nurse working in a pulmonary rehabilitation clinic is conducting an exercise session for a group of clients with chronic obstructive pulmonary disease (COPD). Which exercises will the nurse include because they are most beneficial for clients with COPD? (Select all that apply.)
Stair climbing Squats Lunges The client with COPD most benefits from lower body exercises including lunges, squats, and stair climbing. These exercises are performed as tolerated. Bicep curls and stationary arm bicycle use are beneficial; however, not as beneficial as lower body exercises.
Which diseases do men get more often than women? (Select all that apply.)
Stomach ulcers Abdominal hernias Respiratory diseases
Which oral structures are salivary glands? (Select all that apply.)
Sublingual Parotid Submaxillary
A nurse is caring for a newborn with a congenital malformation of the oral soft palate. The nurse understands that if this malformation is not surgically repaired, the newborn will have future problems. Which problems will this client be at risk for developing in the future if the malformation is not repaired? (Select all that apply.)
Swallowing problems because the soft palate includes the uvula, which aids in swallowing Swallowing problems because the soft palate closes off the esophagus when swallowing Alterations of the soft palate may lead to swallowing problems, increasing the risk of aspiration. This is because the soft palate closes off the esophagus when swallowing. The soft palate ends at the back of the mouth as a fold called the uvula, which is largely muscle. When food is swallowed, a reflex causes the soft palate to rise in order to close off the oropharynx.
A nurse is discussing the leading health indicators of Healthy People 2020 with colleagues. What does the nurse answer when asked "What does the "2020" in the title refer to?"
Target year for accomplishment 2020 refers to the target year for accomplishment. It does not refer to the 26 leading health indicators or the 42 topic areas. A corrected vision of 20/20 means normal eyesight, but that measurement is not related to Healthy People.
What are the functions of the nurse in facilitating health promotion efforts? (Select all that apply.)
Teacher Advocate Consultant Coordinator of services
A nurse is providing discharge instructions for a client who has been diagnosed with angina. The nurse educates the client on aerobicexercise, as per the healthcare provider's orders. The client asks the nurse, "How will I know when I am working out adequately?" What is the nurse's best response?
The goal for aerobic exercise is to maintain target heart rate within 60%-85% of maximum heart rate. The goal for aerobic exercise is to maintain target heart rate within 60%-85% of maximum heart rate. When an individual exercises, he should experience labored breathing but also maintain ability to carry on a conversation. This is also known as the talk test.
A nurse is performing an oral health nursing assessment on an adult client. The nurse notes the presence of pyorrhea. What does this finding indicate?
The presence of periodontal disease Pyorrhea is the presence of pus at the gums when pressed. This is a manifestation of periodontal disease, not fungal disease. Stomatitis in an inflammation of the mouth, while glossitis is the inflammation of the tongue.
A community health nurse is providing education to a group of adults about the types of exercise that promote health. Which statements will the nurse include in the teaching? (Select all that apply.)
The talk test may be easier to use than the heart rate calculation for determining effort in aerobic exercise. Isotonic exercises are also known as dynamic exercises. An example of an anaerobic exercise is weight lifting. An example of anaerobic exercise is weight lifting. Isotonic exercises are also known as dynamic exercises. The talk test may be easier to use than the heart rate calculation for determining effort in aerobic exercise. Aerobic exercises, not anaerobic, are exercises where the amount of oxygen taken into the body during exercise is greater than that used to perform the activity. Isometric exercise causes a slight increase in heart rate and cardiac output, but no noticeable increase in blood flow to other parts of the body.
A geriatric nurse is explaining the concept of the illness-wellness continuum to an older couple who have become homebound. Which of the following could the nurse tell them is true about theirsituation? (Select all that apply.)
They will have "good" days and open "bad" days Their perception of each other's health is important. Their perception of their own health is important. In their situation, the couple will have both "good" and "bad" days. Their perception of their own and each other's health is important. They can neither expect to die prematurely nor expect to fully recover mobility.
Why is it important to teach the parents of newborn and infant clients to place infants to sleep on their backs?
To decrease the risk of SIDS
A nurse is caring for a client in a primary care clinic who has osteoporosis but is in otherwise good health. Which statement made by the nurse is most appropriate when teaching this client about the benefits of exercise?
Walking is an excellent choice of exercise for your condition. Walking, or weight-bearing exercise, is most beneficial for the client with osteoporosis who can bear weight. While swimming is a great choice for those who cannot bear weight, this client would best benefit from walking. Weight-bearing exercise does not increase the number of osteoblasts, but instead balances osteoblasts (bone-building cells) with osteoclast (bone-resorption cells).
A nurse is caring for a client with asthma who is hospitalized due to an acute exacerbation of the disease. The nurse tells the client that exercise may be beneficial in the treatment of asthma. Which exercise has been shown to be particularly beneficial for clients with asthma?
Yoga Yoga has been shown to be particularly beneficial for clients with asthma. The other answer choices are good for aerobic conditioning; however, they are not the most beneficial for the client with asthma.
Two nurses, one newly graduated and the other an experienced mentor, are discussing improving documentation of the nursing process. Which statement by the new graduate should be corrected by the mentor?
"Nursing process is a linear five-step method." Nursing process does have five steps but it is not a linear method. It is multidirectional. Nursing process operates as a feedback loop, and is influenced by the preceding and following steps.
A public health nurse is planning an outreach to residents of subsidized housing. The nurse hopes to invite key members of the housing council to look at their own individual health issues. Which type of health promotion program is this?
Health-risk appraisal Because the nurse hopes to help clients look at their own individual health issues, this is a health-risk appraisal program. It is not information dissemination, which gives information to the general public. Because the appraisal has not been done yet, the program is not about lifestyle and behavior changes. The program is about individuals, not about control of the environment.
The nurse is conducting an oral health history during the nursing assessment. Which considerations will be included in this portion of the assessment? (Select all that apply.)
Self-care abilities Past oral problems Frequency of dental visits Hygiene practices Information that is considered during the health history part of the nursing assessment includes: hygiene practices, frequency of dental visits, self-care abilities, and past oral problems. The presence of dental caries will be assessed during the physical exam, not the health history.