Nursing: Semester 1 Lecture Exam 5

True or False The joint commission adopted the concept of pain as the fifth vital sign

TRUE

Healing depends on (select all that apply) A. re-injury B. renewed inflammation C. diet low in protein D. immune system strength

A. re-injury B. renewed inflammation D. immune system strength

The client is one day post-op following a colon resection and there is an order to assist the client to walk in the hallway at least three times while awake. When the nurse delegates this task to the unlicensed assistive personnel (UAP), which instruction by the nurse is most appropriate? "Apply a gait belt around the client's waist if the client reports feeling dizzy." "Allow the client to sit on the side of the bed before assisting the client to stand and walk." "When assisting the client, be sure to ask about the intensity of the pain." "Have the client stand for at least two minutes before starting to walk."

"Apply a gait belt around the client's waist if the client reports feeling dizzy."

A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The nurse should be sure to include which statement when teaching the client about managing this disease? "Continue to get yearly tuberculin skin tests." "Continue to take your medications even when you are feeling fine." "Follow up with your primary care provider in three months." "Isolate yourself from others until you are finished taking your medication."

"Continue to take your medications even when you are feeling fine." The client with TB needs is to understand the importance of medication compliance, even when the client is no longer having any symptoms. TB treatment usually requires a combination of medications with treatment for at least six months. Stopping treatment or skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks after therapy begins. Once clients no longer have a productive cough, they are not considered contagious.

The nurse is discussing dietary intake with an adolescent who has acne. What is the most appropriate statement by the nurse? "Do not use caffeine in any form, including chocolate." "Good nutritional habits promote healthy skin." "Decrease fatty foods from your diet." "Increase your intake of protein and vitamin A."

"Good nutritional habits promote healthy skin." The exact cause of acne is not known, but genetics and hormones (androgens) play a role. Stress, picking or squeezing blemishes and harsh scrubbing can make acne worse. While poor nutrition may make acne-prone teens more susceptible to breakouts, chocolate or greasy foods don't cause acne. Vitamin A helps regulate the skin cycle, but too much can lead to toxic side effects. Teens should simply eat an age-appropriate, well-balanced diet.

**( lewis readings) The nurse is teaching a group of clients about skin cancer. Which client statement indicates the need for further education about reducing the risk of skin cancer? "I wear sunglasses with ultraviolet protective lenses." "I only tan in the controlled setting of a tanning booth." "I found a sunscreen with a sun protective factor of 30." "I make sure to come inside between noon and 2 pm."

"I only tan in the controlled setting of a tanning booth." Tanning booths and sun lamps are no safer than the natural sun in terms of cellular damage and potential for developing skin cancer. The other self-help measures have positive effects on reducing the chance of damage from ultraviolet rays.

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? A. "Can you describe the pain?" B. "Where exactly do you feel the pain?" C. "Which activities make the pain worse?" D. "What other discomfort do you experience?"

"What other discomfort do you experience?" Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

Patients who are at risk for being under-treated for pain due to inability to communicate

-cognitively impaired -infants/toddlers -anesthetized -critically ill -comatose -imminently dying

refers to an inability to move A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

. Immobility

Match the following: 1.Common cold → 2.Osteomyelitis → 3. HIV/AIDS→ chronic infection acute infection latent infection

1.Common cold → acute infection 2.Osteomyelitis → chronic infection 3. HIV/AIDS→ latent infection

Normal WBC range is?

4,500 to 10,000

Which of the following patients is at higher risk for inflammatory reactions? 2-year-old girl with a healthy diet 38-year-old man who is obese 54-year-old woman in menopause 79-year-old man with diabetes

79-year-old man with diabetes

A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for developing a pressure ulcer? An 80 year-old ambulatory client with a history of diabetes mellitus An obese client who uses a wheelchair An incontinent client who has had three diarrhea stools in the past hour A 79 year-old malnourished client on bed rest

A 79 year-old malnourished client on bed rest Weighing significantly less than ideal body weight increases the number and surface area of bony prominences, which are susceptible to pressure ulcers. In addition, malnutrition is a major risk factor for pressure ulcers, from poor hydration and inadequate protein intake. Note that this is a priority question so that all of the clients are at risk for pressure ulcers. However, the question asks for the client with the highest risk.

The nurse is trying to asses for ACUTE pain in a patient with dementia what should she look for (select all that apply) A. Increased blood pressure B. Increased heart rate D. frequent positition changes C. Increased respiratory rate

A. Increased blood pressure B. Increased heart rate C. Increased respiratory rate chronic pain you wont see these changes and you must monitor your patient for subtle changes

The majority of exudate/drainage is composed of which type of WBC during a chronic inflammatory response ? (select all that apply) A. macrophages B. neutrophils C. eosinophils D. lymphocytes

A. macrophages D. lymphocytes

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (select all that apply): A. Applying over-the-counter lotions to skin that is not broken B. Assisting the client with frequent turning to prevent pressure ulcers C. Covering the client who complains of being cold with more blankets D. Placing a sterile gauze pad over broken skin to contain drainage. E. Assessing a patient complaining of an itching rash.

A, B, C, D: All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply): A. A cleansing wound B. Managing pain C. Applying a dry sterile dressing D. Using cold water in the bath

A, B: Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to (select all that apply): A. Wear sunglasses B. Drink plenty of water C. Eat plenty of foods high in vitamin K. D. Apply sunscreen 30 minutes prior to exposure

A, D: Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

A nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when she states: A. "I need to avoid getting infections because they will increase the immune response in my body, which can make SLE worse." B. "I need to be sure to take all the available immunization to keep from getting sick." C. "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D. "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."

A. "I need to avoid getting infections because they will increase the immune response in my body, which can make SLE worse."

Who are at risk for impaired skin integrity select all that apply A. 45 y/o female receiving radiation therapy due to thyroid CA B. 78 y/o obese male who has pedal edema and consumes a low protein diet C. 25 y/o light skin female who does not wear sun screen daily with family hx of skin CA D. 55 y/o male with controlled diabetes who maintains regular physical activity E. 88 y/o female who is bed bound and is turned every 3-4 hours

A. 45 y/o female receiving radiation therapy due to thyroid CA B. 78 y/o obese male who has pedal edema and consumes a low protein diet C. 25 y/o light skin female who does not wear sun screen daily with family hx of skin CA E. 88 y/o female who is bed bound and is turned every 3-4 hours (* pt should be turned every 1-2 hours)

Histamine produces which important effects during acute inflammation? (Select all that apply.) A. Increases vasodilation B. Enhances vascular permeability C. Promotes T lymphocyte proliferation D. Activates neutrophils E. Mediates early inflammation

A. Increases vasodilation B. Enhances vascular permeability C. Mediates early inflammation Histamine is an important proinflammatory mediator released by mast cells. Similar to serotonin, histamine increases vasodilation, enhances (increases) vascular permeability, and mediates the early acute inflammatory response. Option C is incorrect because interleukin-1 promotes lymphocyte proliferation. Option D is incorrect because platelet-activating factor activates neutrophils.

an immunologic defense against tissue injury, infections, or allergy A. inflammation B. sepsis C. chain of prevention D. antibotics

A. Inflammation

A patient presents with a grade one pressure ulcer. The affected area of skin appears discolored. The skin remains intact, but it may hurt or itch. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Major skin and tissue injury C. Partial thickness injury D. Full thickness injury

A. Intact skin and tissue

Nurse is caring for an immobile patient. What are some consequence of immobiltiy in which she should monitor for (select all that apply) A. Orthostatic hypotension B. Constipation C. Skin break down D. Contracture of joints E. Diarrhea F. Crackles

A. Orthostatic hypotension B. Constipation C. Skin break down D. Contracture of joints F. Crackles--> Atelectasis ( pneumonia....breath sounds are crackles)

A client you are caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be your best response? A. People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." B. He is most likely immunosuppressed from poor nutrition C. He's skin integrity has been compromised due to the foley catheter D. He is most likely immunosuppressed from his disease process or its treatment

A. People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." Explanation: Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment, may have incisions or invasive equipment (e.g., intravenous lines) that compromise skin integrity, or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Although all answers are correct, the most complete answer is A

Function of the skeletal system include all of the following expect: A. acts as the structural foundation for the body B. leverage to move body parts C. supports and protects tissues and internal organs D. attachment sites for ligaments E. stores calcium and vitamin E F. production center for red blood cells

A. acts as the structural foundation for the body B. leverage to move body parts C. supports and protects tissues and internal organs D. attachment sites for ligaments F. production center for red blood cells E. incorrect ...its stores calcium not vitamin e

Musculoskeletal system includes all the following except: A. bones B. joints C. epidermis D. muscle

A. bones B. joints D. muscle

Social factors that influence access treatment to pain (select all that apply) A. income B. education C. geographic location D. gender

A. income B. education C. geographic location

a state or quality of being mobile or movable A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

A. mobility

Which statement are true about the Braden scale (select all that apply) A. screens for skin breakdown for patients in the hospital B. The higher the score the higher the risk for pressure sore development C. sensory perception, moisture, activity, mobility, nutrition, friction and shear are all assessed D. Is a primary prevention tool

A. screens for skin breakdown for patients in the hospital C. sensory perception, moisture, activity, mobility, nutrition, friction and shear are all assessed D. Is a primary prevention tool ( *pp says secondary? book says primary) -The lower the score the higher the risk for pressure sore development -Scoring: 19-23 - not at risk 15-18 - preventative interventions 13-14 - moderate risk 10-12 - high risk 6-9 - very high risk

The nurse is teaching a class of junior high school students about infection control through effective hand washing. The nurse knows that students need further teaching when one states: A. "Hand sanitizer works just as well as washing with soap and water." B. "If I sing the song 'happy birthday' twice through while scrubbing my hands, that should be long enough." C. "I need to read the label on the hand sanitizer to be sure that its at least 60% alcohol." D. "We should all wash hands before eating lunch."

A: Hand sanitizer does not work as well as soap and water, because it is not effective against all pathogens or in all situations. For example, hand sanitizer should not be used when hands are visibly dirty. Repeating the song "Happy Birthday" twice takes about 20 seconds, which is how long hands should be rubbed together with soap. Hand sanitizer needs to be at least 60% alcohol to be effective. Hand washing before eating is recommended by the Centers for Disease Control.

A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. A. Mosquito bites B. Sharing syringe needles C. Breastfeeding a newborn D. Kissing the infected partner E. Anal intercourse

B. Sharing syringe needles C. Breastfeeding a newborn E. Anal intercourse Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or kissing.

The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? Administering two antituberculosis drugs Aminoglycoside antibiotics High doses of B complex vitamins An anti-inflammatory agent

Administering two antituberculosis drugs In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different antitubercule medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid.

*Why is the older population at risk for chronic pain (select all that apply) A. ability to tolerate pain increases B. frequent recipients of surgical procedures C. More likely to suffer from conditions such as DJD and arthritis D. unable to verbalize pain E. part of the aging process F. increase risk of falls

B, C, D, F -Chronic pain is NOT a normal part of aging -ability to tolerate pain decreases -Suffer from many conditions associated with pain→ ( arthritis, changes in spine, musculoskeletal disorders) -Frequent recipients of surgical procedures -Increase risk of falls and trauma -Under-treatment of pain → unable to verbalize pain due to cognitive impairment or may be reluctant to report pain

A 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items near the bed and trying to get out of bed. Which intervention would be most appropriate? Arrange for a sitter to stay with the client Frequently remind the client to stay in bed Request an order for wrist restraints Request an order for antianxiety medication

Arrange for a sitter to stay with the client The plan to use safety protective devices such as wrist restraints should be rethought with a review of other safe actions. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These should be provided by the facility in the event the family cannot do so. This client who has a lung infection and productive cough needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

The nurse observes a physician leave the room of a patient in isolation for Clostridium difficile (C. difficile). The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which of the following actions should the nurse take? A. Nothing.. alcohol-based hand sanitizer kills C. diff B. Ask the physician to wash her hands with soap and water C. report this to upper management D. ask him to put gloves on before seeing the next patient

B. Ask the physician to wash her hands with soap and water Explanation: C. difficile is resistant to alcohol-based and other hand sanitizers; therefore physicians should be instructed to wash their hands with soap and water. The nurse could report the observation to the infection control department, but that does not address the immediate concern of the physician contaminating other patients. There is no need for the room door to be closed. The nurse must take action to ensure the safety of other patients.

The inflammatory process is an anticipated response to tissue injury that produces which desirable outcomes? (Select all that apply.) A.Initial death of tissues B. Eradication of dead tissue C.Formation of scar tissue D. Acute inflammation E. Chronic inflammation

B. Eradication of dead tissue D. Acute inflammation Inflammation is a normal and protective response to injury. Four outcomes are possible, two of which are desirable: acute inflammation and eradication of dead tissue. This process returns tissues to their previously uninjured state. The formation of scar tissue occurs when damaged cells cannot be adequately repaired. This is not the most desirable outcome. Chronic inflammation results when tissue destruction continues and is not a desirable outcome. Initial death of tissue leads to death of the host, a very undesirable outcome.

In regards to the urinary system a patient who is immobile is at most likely at risk for EXCEPT: A. Renal calculi B. Incontinence C. Urinary stasis D. Infection

B. Incontinence

Who is at greatest risk for impaired skin integrity: A. Malnourished B. Infants C. Older adults D. Active children

B. Infants→ diaper rash due to incontinence

the invasion and multiplication of microorganism in the body tissues, which may be clinically inapparent or results in local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response A. Inflammation B. Infection C. chain of prevention D. disseminated infection

B. Infection

The nurse teaches a premenopausal obese client about strategies to prevent osteoporosis. Which strategy identified by the client indicates that the teaching is effective? A. Starts a rapid, strict weight-reduction diet B. Joins a tennis league and practices every day C. Takes 1200 International Units of vitamin D a day D. Signs up for a swimming class three times a week

B. Joins a tennis league and practices every day High-impact exercises (e.g., tennis, running, aerobics, dancing) are best for building bone mass. Weight loss should be slow and reasonable; restricting calories promotes production of the hormone leptin, which stimulates bone loss. The recommended intake of vitamin D for adults younger than 50 years of age (premenopausal women) is 800 International Units; 1200 mg is the recommended daily dose of calcium for adults older than 50 years of age (postmenopausal women). Signing up for a swimming class three times a week may promote overall health and vigor, but it will not increase the strength or mass of bone.

By which method are infections commonly classified? Mode of transmission Trajectory of illness Body system affected Causative microorganism

Causative microorganism infections are classified by mode of transmission, trajectory of illness, and body system affected. However, the most common method of classification is by causative microorganism.

(SKILLS) A patient who has bilateral wrist restraints complains of numbness and tingling in his/her left hand. The nurse notices the patient's left hand is pale and cool to touch ..what should the nurse do next? A. get an order from the provider to take restraints off B. Take the restraint off immediately C. Loosen restraint D. Nothing...the patient is most likely lying

B. Take the restraint off immediately Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the restrained extremity.

The nurse is developing a teaching a plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. The infected area should be covered with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

B. The infected area should be covered with a clean, dry bandage. Rationale A. The client should shower rather than take a tub bath using an antibacterial soap. B. The infected area should be covered with a clean, dry bandage to prevent the spread of infection. C. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. D. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

The state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes A. Pain B. Tissue integrity C. Mobility D. Inflammation

B. Tissue integrity

A newborn has purple skin and bluish hands and feet for 3-4 minutes before it takes its first breath. The nurse knows A. this is a normal finding B. this is a sign of gas a exchange problem C. this is a sign of an infection D. this is a sign of poor tissue integrity

B. this is a sign of gas a exchange problem is a normal finding..HOWEVER, should resolve immediately aka 1-2 minutes....if it doesn't resolve in 1-2 minutes this is a sign of a gas exchange problem

The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. The nurse knows the scar tissue results from: A. Optimal functioning of the inflammatory process after injury B. Fibrous tissue replacing damaged tissue when injury is extensive C. The development of chronic inflammation D. A surgical incision

B: Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nurse assistant indicates that she understands the instruction when she agrees to (select all that apply): A. Bathe and dry the skin vigorously to stimulate circulation B. Keep the head of the bed elevated 3 degrees. C. Offer nutritional supplements and frequent snacks D. Turn the patient at least every 2 hours

C, D: The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? A. "Your primary healthcare provider must have forgotten to prescribe it." B. "Your condition is not severe enough to have physical therapy approved." C. "Your joints are still inflamed, and physical therapy can be harmful." D. "Physical therapy is not helpful for persons who suffer from RA."

C. "Your joints are still inflamed, and physical therapy can be harmful." Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment? A. The client's dietary patterns have changed since admission. B. The client has more difficulty urinating in a supine position. C. Lack of weight-bearing activity promotes bone demineralization. D. Fracture healing requires more calcium, which increases total calcium metabolism.

C. Lack of weight-bearing activity promotes bone demineralization. All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position because of an inability to assume the preferred anatomic position and the emotional effects of using a urinal, it usually does not predispose the client to developing renal calculi. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.

Major reason people seek health care A. Immobility B. Infections C. Pain D. Signs of inflammation

C. Pain

Pt presents with a wound which is red, tender, there is loss of the dermis, and has a some clear fluid oozing from the site. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Minor skin and tissue injury C. Partial thickness injury D. Full thickness injury

C. Partial thickness injury Partial thickness injury-->disruption at the epidermal and dermis layer

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? A.Determine if this is an allergic reaction. B. Elevate the client's head and keep the extremities warm. C. Place the client in the supine position and take the vital signs. D. Tell the client that this is not a typical sensation after receiving morphine sulfate.

C. Place the client in the supine position and take the vital signs. Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.

The older adult client who is bedridden has a documented history of protein deficiency. What will the nurse plan to monitor for? A. Anemia B. Decreased wound healing C. Pressure ulcer development D. Weight gain

C. Pressure ulcer development Rationale A. Anemia has no correlation with this client's protein deficiency. B. The client does not have an indicated wound. C. This client is at risk for pressure ulcer if he or she remains bedridden. D. Weight gain has no correlation with this client's protein deficiency.

**Functions of the Integumentary system include all of the following EXCEPT: A. Aids in protection B. Acts as a barrier from bacteria and virus C. aids in vitamin A absorption D. Insulation E. Sensory perception F. Control of heat regulation G. Aesthetic function

C. aids in vitamin A absorption

Number one way to prevent spread of infection A. wearing gloves B. double glove C. hand washing D. wearing all PPE

C. hand washing

Elderly patients are at risk for impaired mobility due to all the following EXCEPT: A. kyphosis B. decreased bone density C. increased elasticity of ligaments D. reduced muscle tone

C. increased elasticity of ligaments spinal column, a thinning of vertebral disks, shortening of the spinal column, and onset of kyphosis with spinal column compression occur. Bone density decreases and becomes brittle (particularly in females), leaving older adults more susceptible to fracture. Cartilage becomes rigid and fragile, and there is a loss of resilience and elasticity of ligaments. Muscle mass and tone reduce significantly in late adult years. Cumulatively, these changes result in mobility impairment attributable to reduced range of motion and pain in joints, reduced muscle strength, and increased risk for bone fracture.4 D. reduced muscle tone

MRSA, C. diff ,.V.R.E , and TB are all examples of ? A. Fungal infections B. Pandemics C.Health care and community acquired infections D. Parasitic infections

C.Health care and community acquired infections

A patient is contact isolation for a bacterial infection. The nurse is going to implement which of the following interventions for this patient? A. Prevent visitors from entering the room. B. Use the personal protective equipment only when knowingly coming into contact with pathogens C. Help to ensure adequate social interaction and support D. Communicate with the patient over the call light whenever possible

C: Frequently, patients in contact isolation do experience a decrease in social interaction because of the isolation. The nurse must help provide adequate social stimulation for the patient. Frequently, this is done by educating the family and friends regarding isolation practices. Isolation does not mean that the patient cannot have visitors. Visitors must be educated on how to maintain the contact isolation while with the patient, especially hygiene guidelines. Personal protective equipment must be used when entering the room of a patient in contact isolation. Nurses and visitors do not always know when they will come into contact with a pathogen, especially if it is highly virulent. The patient in contact isolation should have regular face-to-face contact with the nurse. The nurse should not use the call light system to communicate with a patient in isolation any more than any other patient.

Which important proinflammatory mediator is responsible for initiating neutrophil and macrophage chemotaxis to the site of tissue injury during inflammation? Leukotrienes Bradykinins Transforming growth factor Complement proteins

Complement proteins Complement proteins are very important, especially C3a, C4a, and C5a, because they initiate chemotaxis (movement) of neutrophils and macrophages toward the site of tissue injury during inflammation

The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient to determine which significant finding? Determines specific causes of inflammation. Identifies the location of inflammation within the body. Confirms the nonspecific presence of inflammation. Indicates a diagnosis of systemic lupus.

Confirms the nonspecific presence of inflammation.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? A. Control of pain B. Immobilization of joints C. Motivation and teaching D. Bladder training and control

Control of pain After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

An elderly bed bound patient who as been neglected presents with a stage 3 pressure ulcer to her buttocks. The nurse is able to see subcutaneous tissue. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Major skin and tissue injury C. Partial thickness injury D. Full thickness injury

D. Full thickness injury Full thickness injury--> all the way down to the subcutaneous, muscle and bone (*stage 2 ulcer would be considered partial thickness)

Populations at greatest risk for immobility A. infants B. low income C. menopausal women D. older adults

D. Older Adult Age 50 and under recommended 1,000mg calcium daily Age 50 + 1,200mg calcium daily along with vitamin D

the client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Perform a total skin self-examination monthly. D. Perform a total skin self-examination monthly with a partner.

D. Perform a total skin self-examination monthly with a partner. Rationale A. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. B. Avoiding sun exposure is a primary prevention. C. A person is physically unable to assess all the skin surfaces of his or her body. D. Performing a monthly total skin self-examination with another person is the best secondary preventive measure.

An African American mother complains of blue-gray or brown spots on the buttocks of her 3 month old baby. What does the nurse suspect? A. Mother is not changing the baby frequently enough B. The baby is having an allergic reaction to the baby powder C. That she will need to call the provider right away D. This is most likely normal and should fade within a year.

D. This is most likely normal and should fade within a year. Normal findings: Mongolian spots → blue-gray or brown spots. They can emerge on the skin of the buttocks or back, mainly in dark-skinned babies. They should fade within a year -acrocyanosis→ Deep red or purple skin and bluish hands and feet. The skin darkens before the infant takes their first breath (when they make that first vigorous cry)....should resolve in 1-2 minutes vernix → A thick, waxy substance covering the skin. This substance protects the fetus's skin from the amniotic fluid in the womb. Vernix should wash off during the baby's first bath. lanugo → Fine, soft hair that may cover the scalp, forehead, cheeks, shoulders, and back. This is more common when an infant is born before the due date. The hair should disappear within the first few weeks of the baby's life.

Which of the following nursing interventions would a nurse be expected to do when caring for a client with syphilis? A. collects health information and a sexual history B. inquires about the client's allergy history C. inform the client that notification of the sexual partner by the department of public health is important for his or her evaluation and treatment. D. All of the above

D. all of the above Explanation: When caring for a client with syphilis, the nurse collects health information and a sexual history, inquires about the client's allergy history in anticipation of antibiotic treatment, and informs the client that notification of the sexual partner by the department of public health is important for his or her evaluation and treatment.

a loss of physical fitness A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

D. deconditioned This applies not only to an athlete who fails to maintain an optimal level of training but also to an individual who does not maintain optimal physical activity.

describes a spread of infection from an initial site to other areas of the body A. systemic infection B. Infection C. chain of prevention D. disseminated infection

D. disseminated infection

*A 5-year-old by with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After toughing the blocks, she rubs her nose with her hand. The mode of transmission is represented by: A. The 5-year-old boy B. The unvaccinated teacher's helper C. The hand-to-nose contact D. The unwashed math blocks

D: The boy has the flu and sneezes into his hand while at school. When he works with the math blocks, he leaves the flu virus on the toys. The teacher's helper picks up the virus with the blocks. When the parent touches her nose with her hand, the virus enters the susceptible host. The blocks act as the mode of transmission. The boy carries the pathogen, and his sneeze is the portal of exit. The teacher's helper is the susceptible host. The hand-to-nose contact is the portal of entry

Integrity system includes all of the following EXCEPT: A. Epidermis B. Dermis C. Subcutaneous tissue D. Hair and nails E. Tendons and ligaments F. Sebaceous glands G. Mucous membranes

E. Tendons and ligaments

All of the following are normal skin findings except: A. Skin pink, warm, dry & intact B. elastic turgor C.No lesions noted D. Mucus membranes moist, intact & pink. E. nail bed with 180 degree angle F. Bony prominences free of redness

E. nail bed with 180 degree angle (this is a sign of clubbing--> should be 160 or less)

A client with considerable pain asks a nurse, "What is your opinion regarding acupuncture as a drug-free method for alleviating pain?" The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of what perspective? Ethnocentrism Prejudice Discrimination Cultural insensitivity

Ethnocentrism Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments.

True or false: A patient who is unconscious can still experience pain

FALSE (power points) Pain is a conscious experience that requires an awareness and sensation via an intact nervous system

TRUE or FALSE: UTI is an example a systemic infection

FALSE it is a local infection NOTE: elderly have weakened immune system and a UTI can very easily become sepsis

TRUE or FALSE : Patients with deeply pigmented skin, skin changes may only be present in fingernail beds

False deeply pigmented patients skin changes can be present in the fingernail beds, lips, mucous membrane of the mouth, underside of hands, and conjunctiva

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with systolic heart failure and an ejection fraction of 30%. Which other finding is most common with this diagnosis? A. Nail clubbing B. Fatigue C. Chest pain D. Peripheral edema

Fatigue Systolic heart failure is the result of a pumping problem, which is why the ejection fraction is reduced (normal is 60%). Heart failure can be caused by a heart attack, but chest pain is not normally a finding in heart failure. Nail clubbing is usually associated with disorders of the lungs. Exertional dyspnea and fatigue are common in clients with left-sided (systolic) heart failure due to fluid backing up into the lungs and pulmonary congestion. Peripheral edema is more commonly seen with right-sided (diastolic) heart failure.

The production of which immune cells are increased following exposure to viral antigens? Basophils Eosinophils Lymphocytes Neutrophils

Lymphocytes Lymphocytes are most prominent in inflammatory responses to viral antigens. Basophils are elevated during chronic inflammation/infections, eosinophils during parasitic infections and allergic reactions, and neutrophils during bacterial infections

The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown? Change the stoma pouch daily Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free Apply antiseptic cream to reddened stoma

Make sure the skin around the stoma is wrinkle-free The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.

Why is inflammation often confused with infection? Prostaglandin hormone mediates both. Purulent drainage is frequently present. Many pathophysiologic processes are shared. They produce comparable immune dysfunction.

Many pathophysiologic processes are shared. Inflammation and infection are commonly confused because many of the pathophysiologic processes associated with one are also found with the other; they overlap. Option A is incorrect because prostaglandin is a proinflammatory hormone that mediates late stages of acute inflammation. Infections are not mediated by such hormones. They are only involved in infections because inflammation occurs when infection occurs. Option B is incorrect because purulent drainage is a sign of infection, but does not occur from inflammation. Option D is incorrect because infection can overwhelm and damage the immune system very quickly (septic shock). Acute inflammation is a protective response. Chronic inflammation, over time, does damage tissue and can be detrimental to the immune system. However, these processes are not comparable.

A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki disease and treatment involving immunoglobulins. The nurse should recognize which scheduled immunizations will be delayed? Inactivated polio vaccine (IPV) Mumps, measles, rubella (MMR) Haemophilus Influenzae Type b (Hib) Diptheria, tetanus, pertussis (DTaP)

Mumps, measles, rubella (MMR) Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body's ability to form antibodies.

The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Readjust the traction for comfort Administer the ordered PRN medication Notify the health care provider Reassess the extremity in 15 minutes

Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.

A nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which activity would be an appropriate diversional activity? Play hand-held games Kick balloons with right leg Play "Simon Says" Throw bean bags

Play hand-held games Immobilization with traction must be maintained until bone ends are in satisfactory alignment and with adequate regrowth of the bone. Activities that increase mobility interfere with the goals of treatment.

Which processes are essential for development of an infection? (Select all that apply) Portal of entry Host Reservoir Microbe Portal of exit Transmission mode

Portal of entry Reservoir Portal of exit Transmission mode The host must be susceptible to infection . Not all microbes cause infection; some are beneficial. Pathogens are microbes that cause infection. All others (portal of entry, reservoir, portal of exit and mode of transmission) are essential processes.

What is the primary purpose of the inflammatory response? Promote healing Facilitate defense Support hemostasis Prevent injury

Promote healing Inflammation is a protective response that minimizes or removes pathologic agents or stimuli that triggered the inflammation, to promote healing.

Which finding differentiates infection from inflammation? Redness Purulence Swelling Tenderness

Purulence Redness, swelling (edema), and tenderness (pain) are signs of both inflammation and infection. The differentiating characteristic/finding is purulence. Purulence is a sign of infection from invasion of pathogenic microorganisms

The RN is responsible for a client in isolation. Which task can be delegated to a practical nurse (PN)? Observation of the client's total environment for risks of harm Assessment of the client's attitude about infection control Reinforcement of isolation precautions with visitors Evaluation of staff compliance with infection control measures

Reinforcement of isolation precautions with visitors PNs and UAPs can reinforce information that was originally given by the RN. The other options are responsibilites of the RN and cannot be delegated.

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? The risk of septicemia and its potential complications from treatment The risk of psychosocial adjustments and resuming previous roles The risk of oral mucous membrane injury and its associated risks The risk of insufficient community resources and emotional support

The risk of septicemia and its potential complications from treatment Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? A. Asking the client's parent B. Using Wong's "Pain Faces" C. Observing the client's body language D. Explaining the use of a 0 to 10 pain scale

Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

*Which property of pathogens makes them capable of producing disease once they invade the body? Pathogenesis Transmissibility Susceptibility Virulence

Virulence refers to the ability of pathogens to produce disease once introduced into the body. Highly virulent pathogens produce disease when small numbers invade the body; weakly virulent pathogens produce disease only when large numbers invade the body.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? a. Incontinence and inability to move independently b. Periodic diaphoresis and occasional sliding down in bed c. Reaction to just painful stimuli and receiving tube feedings d. Adequate nutritional intake and spending extensive time in a wheelchair

a. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

A 24-year-old is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action? a. To prevent transmission of infectious microorganisms b. To control the environment of the patient c. To protect the patient from infectious microorganisms d. To protect only the family

a. To prevent transmission of infectious microorganisms

A bedridden patient who is blind is admitted to a healthcare facility from his or her home with pressure ulcers on the sacral area. Which nursing diagnosis would be a priority? a. Risk for Imbalanced Body Temperature related to stage 2 pressure ulcer b. Impaired Skin Integrity related to immobility c. Feeding Self-Care Deficit related to blindness d. Activity Intolerance related to prolonged bed rest

b. The priority nursing diagnosis for this patient at this moment is Impaired Skin Integrity related to immobility. An end result of the immobility is the development of a pressure ulcer. The other nursing diagnoses may be appropriate but are not the priority on admission to the healthcare facility.

For which illness should airborne precautions be implemented? a. Influenza b. Chickenpox c. Pneumonia d. Respiratory syncytial virus

b. Chickenpox Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a.First-degree skin destruction b.Full-thickness skin destruction c.Deep partial-thickness skin destruction d.Superficial partial-thickness skin destruction

b. full-thickness skin destruction

world wide spread of a disease a. epidemic b. pandemic c. outbreak d. chain of infection

b. pandemic

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a.Use sterile gloves when removing old dressings. b.Wear gowns, caps, masks, and gloves during all care of the patient. c.Administer IV antibiotics to prevent bacterial colonization of wounds. d.Turn the room temperature up to at least 70° F (20° C) during dressing changes.

b. wear gowns, caps, masks, and gloves during all care of the patient

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations? a. Neck hyperextension should be encouraged, particularly in older people. b. Exercises should be continued until the patient is fatigued. c. Exercises should be done frequently to lessen pain for the patient d. Each joint is exercised to the point of resistance but not pain.

d. Each joint is exercised to the point of resistance but not pain.

fever above 101, increased white blood cell count, fatigue, and generalized weakness A. systemic infection B. inflammation C. local infection D. disseminated infection

sepsis--> A. systemic infection

A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by vasodilation. extravasation. neutrophils exudate.

vasodilation.