weeks 4-6 study questions

Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? A. Contusion B. Abrasion C. Laceration D. Avulsion

A. Contusion

Tell whether the following statement is true or false. Diuretics cause increased urine production, resulting in the need for increased urination and possibly urge incontinence. A. True B. False

A. True

critical thinking occurs when a nurse directly apprehends a situation based in its similarity or dissimilarity to other situations

A. True

the patient on a medical unit is scheduled to have a 24-hour urine collection to diagnose a urinary disorder. the nurse should:

A. keep the collection jar on ice

Tell whether the following statement is true or false. A stage 3 pressure injury requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False

A. true

the oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter. A. true B. false

A. true

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A patient who is taking antibiotics for chronic bronchitis A patient diagnosed with type II diabetes A patient who is obese A patient who has a nervous habit of biting his nails A patient diagnosed with prostate cancer A patient whose job involves frequent handwashing

A patient diagnosed with type II diabetes A patient who is obese A patient who has a nervous habit of biting his nails A patient whose job involves frequent handwashing

Which of the following are behaviors of active listening? Select all that apply. A. maintaining an open posture B. Writing down what the patient says C. Establishing and maintaining eye contact D. Nodding in agreement with the patient throughout the conversation E. Responding positively when giving feedback

A, C, D

Tell whether the following statement is true or false. Normal fresh urine has an ammonia odor. A. True B. False

B. False

Tell whether the following statement is true or false. There are no interventions effective for preventing urinary incontinence. A. True B. False

B. False

Tell whether the following statement is true or false. A urine specimen from a patient with an indwelling catheter should be obtained from the collection receptacle. A. True B. False

B. False; the catheter

In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase

C. Proliferation phase

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? Personal Identity Disturbance Body Image Disturbance Self-Esteem Disturbance Altered Role Performance

C. This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. Compare bilateral parts for symmetry. Proceed in a toe-to-head systematic manner. Use standard terminology to report and record findings. Do not allow data from the nursing history to direct the assessment. Document only skin abnormalities on the patient record. Perform the appropriate skin assessment when risk factors are identified.

Compare bilateral parts for symmetry. Use standard terminology to report and record findings. Perform the appropriate skin assessment when risk factors are identified.

Which term describes a condition in which 24-hour urine output is less than 50 mL? A. Dysuria B. Glycosuria C. Pyuria D. Anuria

D. Anuria

Which wound complication is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration

D. Maceration

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. It promotes the patient's sense of well-being. It prevents deterioration of the oral cavity. It contributes to decreased incidence of aspiration pneumonia. It eliminates the need for flossing. It decreases oropharyngeal secretions. It helps to compensate for an inadequate diet.

It promotes the patient's sense of well-being. It prevents deterioration of the oral cavity. It contributes to decreased incidence of aspiration pneumonia.

what does the urinary system include?

Kidneys and ureters Bladder Urethra

Ergonomics means

Making changes to the job to fit the worker

Reasons for Catheterization

Relieving urinary retention Prolonged patient immobilization Obtaining a sterile urine specimen when patient is unable to void voluntarily Accurate measurement of urinary output in critically ill patients Assisting in healing open sacral or perineal wounds in incontinent patients Emptying the bladder before, during, or after select surgical procedures and before certain diagnostic examinations. Providing improved comfort for end-of-life caref

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? When the patient had his or her most recent bath The patient's usual hygiene practices and preferences Where the bathing fits in the nurse's schedule The time that is convenient for the patient care assistant

The patient's usual hygiene practices and preferences

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? Bathe the patient more frequently. Use an emollient on the dry skin. Massage the skin with alcohol. Discourage fluid intake.

Use an emollient on the dry skin.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. A. Serous drainage is composed of the clear portion of the blood and serous membranes. B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. C. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. D. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. E. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. F. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. Progressive muscle relaxation Meditation Anticipatory socialization Biofeedback Rhythmic breathing Guided imagery

a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet, but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. A. Use standard precautions or transmission-based precautions when indicated. B. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. C. Clean the wound in full or half circles beginning on the outside and working toward the center. D. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. E. Clean to at least 1 in beyond the end of the new dressing if one is being applied. F. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. Changes in appetite Changes in elimination patterns Decreased pulse and respirations Use of ineffective coping mechanisms Withdrawal Attention-seeking behaviors

a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. Increased heart rate Decreased muscle strength Increased mental alertness Increased blood glucose levels Decreased cardiac output Decreased peristalsis

a, c, d. The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest.

After instituting a new system for recording patient data, a nurse evaluates the "usability" of the system. Which actions by the nurse BEST reflect this goal? Select all that apply. The nurse checks that the screens are formatted to allow for ease of data entry. The nurse reorders the screen sequencing to maximize effective use of the system. The nurse ensures that the computers can be used by specified users effectively. The nurse checks that the system is intuitive, and supportive of nurses. The nurse improves end-user skills and satisfaction with the new system. The nurse ensures patient data is able to be shared across health care systems.

a, c, d. Usability refers to the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. Checking that screens are formatted to allow ease of data entry, ensuring that computers can be used by specified users effectively, and checking that the system is intuitive and supportive of nurses are all tasks related to the "usability" of the system. Reordering screen sequencing to maximize use and improving end-user skills and satisfaction with the new system refers to optimization. The ability to share patient data across health care systems is termed interoperability.

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. The nurse makes a point to address the patient by name upon entering the room. The nurse avoids fatiguing the patient by performing all procedures in silence. The nurse performs care in a manner that respects the patient's privacy and sensibilities. The nurse offers the patient a simple explanation before moving her in any way. The nurse ignores negative feelings from the patient since they are part of the grieving process. The nurse avoids conversing with the patient about her life, family, and occupation.

a, c, d. When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. A. Hemostasis occurs immediately after the initial injury. B. A liquid called exudate is formed during the proliferation phase. C. White blood cells move to the wound in the inflammatory phase. D. Granulation tissue forms in the inflammatory phase. E. During the inflammatory phase, the patient has generalized body response. F. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. Bathe the feet thoroughly in a mild soap and tepid water solution. Soak the feet in warm water and bath oil. Dry feet thoroughly, including the area between the toes. Use an alcohol rub if the feet are dry. Use an antifungal foot powder if necessary to prevent fungal infections. Cut the toenails at the lateral corners when trimming the nail.

a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. A 78-year-old male patient diagnosed with an enlarged prostate An 83-year-old female patient who is on bedrest A 75-year-old female patient who is diagnosed with vaginal prolapse An 89-year-old male patient who has dementia A 73-year-old female patient who is taking antihistamines to treat allergies A 90-year-old male patient who has difficulty walking to the bathroom

a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. Teach the parents to reinforce their child's positive qualities. Teach the parents to overlook occasional negative behavior. Teach parents to ignore neutral behavior that is a matter of personal preference. Teach parents to listen and "fix things" for their children. Teach parents to describe the child's behavior and judge it. Teach parents to let their children practice skills and make it safe to fail.

a, c, f. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.

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. Stop performing the exercises. Decrease the number of repetitions performed. Reevaluate the nursing care plan. Move to the patient's other side to perform exercises. Encourage the patient to finish the exercises and then rest. Assess the patient for other symptoms.

a, c, f. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. Measure the patient's fluid intake and output. Keep the skin around the stoma moist. Empty the appliance frequently. Report any mucus in the urine to the primary care provider. Encourage the patient to look away when changing the appliance. Monitor the return of intestinal function and peristalsis.

a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.

A nurse is using the steps in informatics evaluation to evaluate the use of a portal as a patient resource. What are examples of activities that might occur in the "determining the question" step? Select all that apply. The nurse develops a clear, focused question to determine the data to be collected. The nurse determines what to evaluate. The nurse determines how the data ultimately should be reported. The nurse decides what specific data elements need to be collected. The nurse clarifies exactly how the data will be collected. The nurse performs comprehensive documentation of the data collected.

a, c. The nurse develops a clear, focused question to determine the data to be collected and the nurse determines how the data ultimately should be reported during the "determine the question" step. The nurse determines what to evaluate during the step "determine what will be evaluated." The nurse decides what specific data elements need to be collected during the "determine the needed data" step. The nurse clarifies exactly how the data will be collected during the "determine the data collection method and sample size" step. The nurse performs comprehensive documentation of the data collected during the "document your outcome evaluation" step.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. Group decision making Group leadership Group power Group identity Group patterns of interaction Group cohesiveness

a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.

For male and female patients, wash the groin area with a small amount of soap and water and rinse. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. For male and female patients, always proceed from the most contaminated area to the least contaminated area. For male and female patients, use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.

1. A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. Instruct the patient to avoid sudden position changes that may cause dizziness. Recommend that the patient restrict fluid until after exercising is finished. Instruct the patient to push a little further beyond fatigue each session. Instruct the patient to avoid exercising in very cold or very hot temperatures. Encourage the patient to modify exercise if weak or ill. Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. Wash the skin twice a day with a mild cleanser and warm water. Use cosmetics liberally to cover blackheads. Use emollients on the area. Squeeze blackheads as they appear. Keep hair off the face and wash hair daily. Avoid sun-tanning booth exposure and use sunscreen.

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? Pain Anxiety Depression Fluid volume deficit

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? Monitoring food and drink temperatures to prevent burns Providing adequate pain relief measures to reduce stress Monitoring for depression related to social isolation Providing meals high in carbohydrates to promote healing

a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services and U.S. Department of Agriculture.

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? A toddler playing with his 9-year-old brother's construction set A 4-year-old eating yogurt for lunch An infant covered with a small blanket and asleep in the crib A 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks.

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? "I need to identify the problem first." "Listing alternatives is the initial step." "I will list alternatives after I develop the plan." "I do not need to evaluate the outcome of my plan."

a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified.

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? Personal Identity Disturbance Body Image Disturbance Self-Esteem Disturbance Altered Role Performance

a. An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) A young clergyperson whose vocal cords are paralyzed after a motorbike accident A 32-year-old accountant who survives a massive heart attack A 23-year-old model who just learned that she has breast cancer

a. Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach, the 32 year old's massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? The male urethra is more vulnerable to injury during insertion. In the hospital, a clean technique is used for catheter insertion. The catheter is inserted 2 to 3 in into the meatus. Since it uses a closed system, the risk for UTI is absent.

a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? The nurse leaves the patient in a sitting position while the family visits. The nurse places identification tags on both the shroud and the ankle. The nurse removes soiled dressings and tubes. The nurse makes sure a death certificate is issued and signed

a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat.

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? Decreased and highly concentrated Decreased and highly dilute Increased and concentrated Increased and dilute

a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? Apply gentle pressure on the lower eyelid to center the lens prior to removing it. Move the eyelids toward one another to cause the lens to slide out between the eyelids. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. Have the patient look forward, retract the lower lid, and move the lens down on the sclera.

a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye.

Population health addresses the health status and health issues of aggregate populations and addresses ways in which resources may be allocated to address these concerns. What is the driving force behind the use by health corporations of analytics and big data to support population health? The transition from fee-for-service models to value-based payment models A growing older population with more complicated health needs The overcrowding and understaffing of hospitals The shortage of health care professionals, particularly nurses

a. Information technology is a part of the core infrastructure on which population health can be assessed and addressed. As organizations transition from the traditional fee-for-service model to value-based payment models (including ACOs), data, information, and knowledge about populations rather than individual patients will be required. A growing older population with more complicated health needs, the overcrowding and understaffing of hospitals, and the shortage of health care professionals, particularly nurses, may be affected by population health assessment, but are not the driving force for the development of this technology.

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? "Are you worried about failing your exams?" "Have you been staying up late studying?" "Are you using any recreational drugs?" "Do you have trouble managing your time?"

a. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress.

A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish red today; is there something wrong with me?" What would be the nurse's best response? "This is a normal finding when taking phenazopyridine." "This may be a sign of blood in the urine." "This may be the result of an injury to your bladder." "This is a sign that you are allergic to the medication and must stop it."

a. Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the patient needs to be aware of this.

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? Carefully assessing the patient care environment Using two nurses to lift a patient who cannot assist Wearing a back belt to perform routine duties Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? Cliché Giving advice Being judgmental Changing the subject

a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A patient problem list Narrative notes describing the patient's condition Overall trends in patient status Planned interventions and patient outcomes

a. The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? A. Document the findings and continue to monitor the patient. B. Administer antipyretics, as prescribed. C. Increase the frequency of assessment to every hour and notify the patient's primary care provider. D. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? Preventing the tubing from kinking to maintain free urinary drainage Not removing the sheath for any reason Fastening the sheath tightly to prevent the possibility of leakage Maintaining bedrest at all times to prevent the sheath from slipping off

a. The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? "New mothers need support." "The lack of a father is difficult." "How are you today?" "It is a very sad situation."

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

When a fire occurs in a patient's room, what would be the nurse's priority action? Rescue the patient. Extinguish the fire. Sound the alarm. Run for help.

a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate.

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? Realistic and positively motivating his development Unrealistic and negatively motivating his development Unrealistic but positively motivating his development Realistic but negatively motivating his development

a. The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? Support weight on stronger leg and cane and advance weaker foot forward. Hold the cane in the same hand of the leg with the most severe deficit. Stand with as much weight distributed on the cane as possible. Do not use the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? Determining the progress made in achieving established goals Clarifying when the patient should take medications Reporting the progress made in teaching to the staff Including all family members in the teaching session

a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? A. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. B. Draw the shape of the wound and describe how deep it appears in centimeters. C. Gently insert a sterile applicator into the wound and move it in a clockwise direction. D. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

A nurse who reassures herself that she is prepared to speak in front of a group of her peers is using which of the following types of communication? A. Intrapersonal B. Interpersonal C. Group D. Organizational

a. interpersonal

a nurse visits an elderly patient at home and assesses the safety of the patients environment. which of the following articles can be a threat to the patients safety?

area rugs kept on the stairs without carpet

while bending forward, you spend 30 minutes feeding a patient on best rest. What is (are) the musculoskeletal risk factor(s) in the situation?

awkward posture long duration

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. News media are preparing a report on the condition of a patient who is a public figure. Data are needed for the tracking and notification of disease outbreaks. Protected health information is needed by a coroner. Child abuse and neglect are suspected. Protected health information is needed to facilitate organ donation. The sister of a patient with Alzheimer's disease wants to help provide care.

b, c, d, e. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. A. The patient takes time to think about responses to questions. B. The patient is 86 years old. C. The patient reports inability to control urine. D. The patient is scheduled for a hip arthroplasty. E. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). F. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

Nurses incorporate telecare in patient care plans. Which services are MOST representative of this technologic advance? Select all that apply. Diagnostic testing Easy access to specialists Health and fitness apps Early warning and detection technologies Digital medication reminder systems Monitoring of progress following treatment

b, c, d. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems, and early warning and detection technologies. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Examples include conducting diagnostic tests, monitoring a patient's progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. Do full-body pushups in bed six to eight times daily. Breathe in and out smoothly during quadriceps drills. Place the bed in the lowest position or use a footstool for dangling. Dangle on the side of the bed for 30 to 60 minutes. Allow the nurse to bathe the patient completely to prevent fatigue. Perform quadriceps two to three times per hour, four to six times a day.

b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A patient who is older than 50 A patient who has already fallen twice A patient who is taking antibiotics A patient who experiences postural hypotension A patient who is experiencing nausea from chemotherapy A 70-year-old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? The patient will make above-B grades in all tests at school. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. The patient reports that she feels more self-confident in her music and art, which she enjoys. The patient expresses that she is very smart in school.

b. All of these patient goals may be appropriate for the patient, but the only goal that directly addresses her body image disturbance is "the patient will demonstrate by diet control and skin care, increased interest in control of acne."

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A 4-month-old infant who is unable to roll over A 6-month-old infant who is unable to hold his head up himself An 11-month-old infant who cannot walk unassisted An 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? Projection Denial Displacement Repression

b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing, in this case receiving a diagnosis of pancreatic cancer. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness. In the case described in question 9, the patient is not blocking out the fact that the diagnosis was made, the patient is refusing to believe it.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" "I will need to call in on the 8th of August because I have a doctor's appointment." "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? Supination Dorsiflexion Hyperextension Abduction

b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? Pouring warm water over the patient's fingers. Having the patient ignore the urge to void until her bladder is full. Using a warm bedpan when the patient feels the urge to void. Stroking the patient's leg or thigh.

b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? Improved renal blood supply to the kidneys Urinary stasis Decreased urinary calcium Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? "I must breathe in and out in rhythm." "I should take my pulse and expect it to be faster." "I can expect my muscles to feel less tense." "I will be more relaxed and less aware."

b. No matter what the technique, relaxation involves rhythmic breathing, a slower (not a faster) pulse, reduced muscle tension, and an altered state of consciousness.

A nurse is using informatics technology to decide which patients may be at risk for readmission. What is the term for this type of analytic? Data visualization Predictive analytics Big data Data recall

b. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, this is used by organizations to attempt to identify patients who are at risk for readmission so case managers can intervene. Data visualization is the presentation of data in a pictorial or graphical format for analysis. Big data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data recall is not a technical term for analytics.

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? A. Irrigate the wound. B. Provide gentle cleansing of the wound. C. Debride the wound. D. Change the dressing frequently.

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

A home health care nurse is using the steps of the SDLC, to design a new system for home health care documentation. The nurse analyzes the old system and develops plans for the new system. What is the next step of the nurse in this process? Test Design Implement Evaluate

b. The SDLC requires focus in the areas of Analyze and Plan, Design and Build, Test, Train, Implement, Maintain, and Evaluate. After analyzing and planning the new system, the nurse would move on to the design step in which the basic design of the new system is developed. The nurse would then test the system, train employees, and implement, maintain, and evaluate the new system in that order.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? "Would you prefer a bath or a shower?" "May I help you with a bed bath now or later this morning?" "I will be giving you your bath. Do you use soap or shower gel?" "I prefer a shower in the evening. When would you like your bath?"

b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? The nurse positions a patient in a supine position prior to applying wrist restraints. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do.

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? Erase or use correcting fluid to completely delete the error. Mark the entry "mistaken entry"; add correct information; date and initial. Use a permanent marker to block out the mistaken entry and rewrite it. Remove the page with the error and rewrite the data on that page correctly.

b. The nurse should not use dittos, erasures, or correcting fluids when correcting documentation; block out a mistake with a permanent marker; or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

A nurse caring for a patient's hemodialysis access documents the following: "5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? Positive bruit noted. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive thrill noted.

b. The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? Use the axillae to bear body weight. Keep elbows close to the sides of the body. When rising, extend the uninjured leg to prevent weight bearing. To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? Lack of self-esteem Deficient self-knowledge Unrealistic self-expectation Inability to evaluate himself

b. The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A closed-ended answer Information clarification The nurse to give advice Assertive behavior

b. The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.

A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? The nurse would use different equipment for catheterization of male versus female patients. The nurse should use the smallest appropriate indwelling urinary catheter. The nurse should always sterilize the equipment prior to insertion. The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.

b. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient (ANA, 2014; SUNA, 2015a). The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16F gauge commonly used (Bardsley, 2015a). A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise (ANA).

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? 2 4 5 6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? Personal Identity Disturbance Body Image Disturbance Self-Esteem Disturbance Altered Role Performance

b. This patient's concern is with body image. The information provided does not suggest a nursing diagnosis of Personal Identity Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? Do not remove or wash the piercings without permission from the patient. Rinse the sites with warm water and remove crusts with a cotton swab. Wash the sites with alcohol and apply an antibiotic ointment. Remove the jewelry and allow the sites to heal over.

b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)

what can the nurse do to prevent falls in a healthcare facility? select all that apply

b. keep bed in the lowest position d. keep wheels on bed and wheelchair locked e. provide nonskid footwear f. answer call bell promptly

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. A. Notify the health care provider of the situation. B. Cover the exposed tissue with sterile towels moistened with sterile C. 0.9% sodium chloride solution. D. Place the patient in the low Fowler's position.

c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. Sixty percent of U.S. fire deaths occur in the home. Most fatal fires occur when people are cooking. Most people who die in fires die of smoke inhalation. Fire-related injury and death have declined due to the availability and use of smoke alarms. Fires are more likely to occur in homes without electricity or gas. Fires are less likely to spread if bedroom doors are kept open when sleeping.

c, d, e. Of all fire deaths in the United States, 80% occur in the home (Warmack, Wolf, & Frank, 2015). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the significant decline in fire-related injury and death. People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. Fill the silence with lighter conversation directed at the patient. Use the time to perform the care that is needed uninterrupted. Discuss the silence with the patient to ascertain its meaning. Allow the patient time to think and explore inner thoughts. Determine if the patient's culture requires pauses between conversation. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. Wear underwear with a synthetic crotch Take baths rather than showers Drink 8 to 10 8-oz glasses of water per day Drink a glass of water before and after intercourse and void afterward Dry the perineal area after urination or defecation from the front to the back Observe the urine for color, amount, odor, and frequency

c, e, f. It is recommended that a healthy adult drink 8 to 10 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

A nurse designing a new EHR system for a pediatric office follows usability concepts in system design. Which concepts are recommended in system design? Select all that apply. Users should not explore with forgiveness for unintended consequences. Shortcuts for frequent users should not be incorporated into the system. Content emphasis should be on information needed for decision making. The less times users need to apply prior experience to a new system the better. All the information needed should be presented to reduce cognitive load. The number of steps it takes to complete tasks should be minimized.

c, e, f. When designing a system, content emphasis should be on information needed for decision making. All the information needed should be presented to reduce cognitive load. The number of steps it takes to complete tasks should be minimized. The more users can apply prior experience to a new system, the lower the learning curve, the more effective their usage, and the fewer their errors. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. This approach accelerates learning while building in protections against unintended consequences. One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: Grasp the gait belt. Stay with the patient and call for help. Place feet wide apart with one foot in front. Gently slide patient down to the floor, protecting her head. Pull the weight of the patient backward against your body. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A. Enhanced healing due to the presence of sugars and proteins B. Delayed healing due to dead tissue present in the wound C. Decreased effectiveness of antibiotics against the bacteria D. Impaired skin integrity due to overhydration of the cells of the wound E. Delayed healing due to cells dehydrating and dying F. Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? The nurse teaches a patient rhythmic breathing to perform prior to the procedure. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient know what to expect—for example, when the nurse tells the patient about the pain he or she should expect to experience during a procedure, and describes related pain relief measures—the patient's anxiety is reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? Impaired gas exchange related to cigarette smoking Anxiety related to inability to stop smoking Risk for suffocation related to unfamiliarity with fire prevention guidelines Deficient knowledge related to lack of follow-through of recommendation to stop smoking

c. Because the patient is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? Determining the established goals of the institution Ensuring that verbal and nonverbal communication is congruent Engaging in self-talk to plan the day and decrease fear Speaking with fellow colleagues about how they feel

c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

Nurses test new technology in phases. In which phase would the nurse "test drive" the new system? Unit Function User acceptance Integration

c. During the phase "user acceptance," the nurse would "test drive" the new system to ensure it's working as designed. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? "I love my child so much I 'hug him to death' every day." "I think children need challenges, don't you?" "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

c. Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? Dorsal recumbent position Lateral position Fowler's position Sims' position

c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? Wait a few minutes and then continue the move to the chair. Call for assistance and continue the move with the help of another nurse. Lower the patient back to the side of the bed and pivot her back into bed. Have the patient sit down on the bed and dangle her feet before moving.

c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." Try calling another resident for the order or wait until the next shift.

c. In most facilities, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order.

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? Teach the patient that incontinence is a normal occurrence with aging. Ask the patient's family to purchase incontinence pads for the patient. Teach the patient to perform PFMT exercises at regular intervals daily. Insert an indwelling catheter to prevent skin breakdown.

c. Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment.

A nurse is using information from informatics technology that is synthesized so that relationships between lung cancer diagnoses and smoking are identified. What part of "DIKW" does this represent? Data Information Knowledge Wisdom

c. Knowledge is Information that is synthesized so that relationships are identified. Data refer to discrete entities that are described without interpretation. Information is data that have been interpreted, organized, or structured. Wisdom is the appropriate use of knowledge to manage and solve human problems.

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? Add bath oil to the water to prevent dry skin. Allow the patient to lock the door to guarantee privacy. Assist the patient in and out of the tub to prevent falling. Keep the water temperature very warm because older adults chill easily.

c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? An infant who learns to turn over A school-aged child who learns how to add and subtract An adolescent who is a "loner" A young adult who has a variety of friends

c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? Decreasing pulse Increasing sleepiness Increasing energy levels Decreasing respirations

c. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness.

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? Negative self-concept and low self-esteem Negative self-concept and high self-esteem Positive self-concept and fairly high self-esteem Positive self-concept and low self-esteem

c. The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient?Recommend that she discipline her daughter more strictly and consistently.Make a list of things her husband can do to give her more time and help her improve her parenting skills.Assist the mother to identify both what she believes is preventing her success and what she can do to improve.Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

c. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? Irrigation of long-term urinary catheters is a routine order. Irrigation is recommended to prevent the introduction of pathogens into the bladder. A blood clot threatens to block the catheter. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.

c. The flushing of a tube, canal, or area with solution is called irrigation. Natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA, 2015a). However, intermittent irrigation is sometimes prescribed to restore or maintain the patency of the drainage system. Sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter.

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 from 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 applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient?Ineffective Coping related to the new parenting role Ineffective Denial related to ability to care for a newborn Anxiety related to change in role status Situational Low Self-Esteem related to fear of parenting

c. The most appropriate nursing diagnosis is Anxiety, which indicates situational/maturational crises or changes in role status. Ineffective Coping refers to an inability to appraise stressors or use available resources. Ineffective Denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem refers to feelings of worthlessness related to the situation the person is currently experiencing, not to the fear of role changes.

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? Shift the focus of the interaction to the "process of bathing." Wash the face and hair at the beginning of the bath. Consider using music to soothe anxiety and agitation. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? Have the patient extend his arms outward and cross his legs on top of a pillow. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. Have the patient cross his arms on his chest and place a pillow between his knees. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. Cut the gown with scissors to allow arm movement. Thread the bag and tubing through the gown sleeve, keeping the line intact. Temporarily disconnect the tubing from the IV container, threading it through the gown.

c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? A. Pain B. Impaired Skin Integrity C. Disturbed Body Image D. Disturbed Thought Processes

c. Wounds cause emotional as well as physical stress.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." "You want me to discontinue the PCA pump until you see him tonight at patient rounds." "I am Rosa Clark, an RN working on the second floor of South Street Hospital." "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? Arrange to have the infant removed from the home. Inform other members of the family of the situation. Increase the number of visits by the visiting nurse. Notify the care provider and recommend respite care for the mother.

d. A person providing care at home for a family member for long periods of time often experiences caregiver burden, which may be manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker or arrange for respite care for the family.

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? The stoma is hard and dry. The stoma is a pale pink color. The stoma is swollen. The stoma is a purple-blue color.

d. A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color.

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? The nurse includes suggestions on how to prevent the incident from recurring. The nurse provides minimal information about the incident. The nurse discusses the details with the patient before documenting them. The nurse records the circumstances and effect on the patient in the medical record.

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident, and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? "I'm sorry, but patients are not allowed to copy their medical records." "I can make a copy of your record for you right now." "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? A. Using sterile dressing supplies B. Suggesting dietary supplements C. Applying antibiotic ointment D. Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. Even small doses of radiation result in bone marrow depression and cancer. BLI is a serious consequence following detonation of an explosive device.

d. BLI is a recognized consequence following exposure to an explosive device. The CDC is the federal facility that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one third of survivors) may exhibit posttraumatic stress disorder.

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? Checking to make sure fire alarms are working properly. Preventing exposure to temperature extremes. Screening for partner or elder abuse. Making sure patient rooms are decluttered.

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? "Patient displays moderate anxiety related to her situation." "Patient manifests panic related to feelings of impending doom." "Patient describes severe anxiety related to her situation." "Patient expresses fear of her husband."

d. Fear is a feeling of dread in response to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation.

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? Make a recommendation for the patient to see an oral surgeon. Report the condition to the primary care provider. Gently scrape the oral cavity with a tongue depressor. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor.

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? Personal Identity Disturbance Body Image Disturbance Self-Esteem Disturbance Altered Role Performance

d. Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? The incontinence pattern State of physical mobility Medications being taken Age of the patient

d. Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the care plan.

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? Explain how to use the telephone. Introduce the patient to her roommate. Review the hospital policy on visiting hours. Explain how to operate the call bell.

d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? Discouraging oververbalization of fears and anxieties Focusing on the outcome as opposed to the details of the surgery Providing time alone for reflection on personal strengths and weaknesses Mutually determining expected outcomes of the care plan

d. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. The nurse should explain all procedures and sensations likely to be experienced during the procedures, and stay with the patient to promote safety and reduce fear.

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? Every 3 hours Every 4 hours Daily As needed

d. PRN means "as needed"—not every 3 hours, every 4 hours, or once daily.

A nurse is testing a new computer program designed to store patient data. In what phase of testing would the nurse determine if the system can handle high volumes of end-users or care providers using the system at the same time? Unit Function Integration Performance

d. Performance testing is more technical and ensures proper functioning of the system when there are high volumes of end-users or care providers using the system at the same time, ensuring it can handle the load. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? "Do you take two injections of insulin to decrease the complications?" "Most health care providers recommend diet and exercise to regulate blood sugar." "Most complications of diabetes are related to neuropathy." "What specific complications have you experienced?"

d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? They prevent confused patients from wandering. A history of a previous fall from a bed with raised side rails is insignificant. Alternative measures are ineffective to prevent wandering. A person of small stature is at increased risk for injury from entrapment.

d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident.

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? "You need to speak to the patient quietly so you don't disturb the other patients." "Let me help you with your transfer technique." "When you are finished, be sure to apologize for your rough demeanor." "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? Inform the family that there is no need for them to wash the body since the mortician typically does this. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? Negative self-concept Modesty (lack of conceit) Body image disturbance Low self-esteem

d. The nurse can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (what we think we really are) and the "ideal self" (what we think we would like to be). The nurse would have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? "I'm just the IV therapist checking your IV." "I've been transferred to this division and will be caring for you." "I'm sorry, my name is John Smith and I am your nurse." "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? Administer activated charcoal in tablet form and take child to the ED. Administer syrup of ipecac and take child to the ED. Bring the child in to the primary care provider for gastric lavage. Call the PCC immediately before attempting any home remedy.

d. The nurse should tell the parents to call the PCC immediately, before attempting any home remedy. Parents may be instructed to bring the child immediately to an emergency facility for treatment. Activated charcoal is considered the most effective agent for preventing absorption of the ingested toxin. It is not recommended for storage or use at home. Activated charcoal can be administered through a nasogastric tube in the ED for serious poisonings after the risks and benefits have been determined. Syrup of ipecac is no longer recommended because vomiting may be dangerous. A toxic substance may prove more hazardous coming up rather than when it was swallowed. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? Side-lying Fowler's Sims' Prone

d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? There is no disturbance in self-concept. This patient has ego strength and high self-esteem but may have a disturbance of body image. The area of self-esteem has very low priority at this time and should be ignored until much later. It is probable that there are disturbances in self-esteem and body image.

d. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? The use of reflective questions The use of closed questions The use of assertive questions The use of clarifying questions

d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." The nurse places a hand on the patient's arm and states, "You feel so alone." The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." The nurse holds the patient's hand and asks, "What makes you feel so alone?"

d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

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? Sitting him in a geriatric chair near the nurses' station Using the sheets to secure him snugly in his bed Keeping the bed in the high position Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall.

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? A. Keeping the head of the bed elevated as often as possible B. Massaging over bony prominences C. Repositioning bed-bound patients every 4 hours D. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? Use hydrogen peroxide on a clean washcloth to wipe the eyes. Wipe the eye from the outer canthus to the inner canthus. Position the patient on the opposite side of the eye to be cleansed. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

d. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? Admission sheet Admission nursing assessment Flow sheet Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet.

the nurse instructs the family of an elderly patient with a visual impairment and decreased mobility that a common problem for these patients is related to

falls

a nurse finds a client in his room asphyxiated (oxygen deficiency) with carbon monoxide (CO) inhalation. Which of the following activities should be of highest priority for the nurse?

get the victim out of the present environment

The goal of patient care ergonomics is to

help you feel and work better

a staff nurse asks you ti help her perform a lift you feel is unsafe. what would be your best response?

let me check with my instructor if i am allowed to help lift this patient

Why are mechanical aides needed for patient handling?

manual lifting techniques are not sufficient to protect nurses from injury

use of a gait belt Freduces what risk factor from moving patients that isn't present when moving boxes?

no handles

A nurse is caring for a patient who is receiving an intravenous therapy through an IV pump. which of the following interventions should the nurse implement to ensure electrical safety?

obtain a three prong grounded plug adapter

What are the age-related changes in older adult that may affect their safety? Select all that apply

reduced vision and hearing polypharmacy effects of drugs in the aging body

the purpose of assessing tasks and surroundings for risk factors is to

take steps to protect yourself

which of the following patient care tasks involve heavy lifting?

transferring an immobile patient

Which of the following is a work environment factor that can reduce safety for both patient and caregiver?

uneven work surfaces

If you had to transfer a totally dependent patient from a nonadjustable stretcher to a nonadjustable bed of different heights, what is the best step you could take to reduce the musculoskeletal risk factors?

use a friction-reducing device when transferring

stages of pressure injuries

vStage 1: nonblanchable erythema of intact skin vStage 2: partial-thickness skin loss with exposed dermis vStage 3: full-thickness skin loss; not involving underlying fascia vStage 4: full-thickness skin and tissue loss vUnstageable: obscured full-thickness skin and tissue loss vDeep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration