Exam #5 (Stinky Feet Game)

A nurse is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make?

"At this stage, children tend to become modest and value their privacy".

A nurse is discussion the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client?

"I will ask the client if they want to schedule sometimes to pray during the day"

After an educational session, a new mother is repeating the key concepts related to infant bed safety to the nurse. Which statements indicate a need for more teaching?

"I will place my son on his belly to sleep"

A nurse is reviewing safety measures with the parent of an 8-month-old infant. Which of the following statements by the parent indicates an understanding of safety for the infant?

"My baby loved to play with the crib gym, but I took it out of the crib".

A nurse is talking with guardians who are concerned about several issues with their preschoolers. Which of the following issues should the nurse identify as the priority?

"My child has temper tantrums every time we tell them to do something they don't want to do"

Which of the following is an example of health disparity? (Select all the apply, 3 correct) A- A patient who has a homosexual sexual preference B- A patient unable to access primary care services C- Patients living with chronic disease D- A family who relies on public transportation E- A patient who has had a history of smoking for 10 years

B- A patient unable to access primary care services C- Patients living with chronic disease E- A patient who has had a history of smoking for 10 years BCE

A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include?

"Position the car seat so that the infant is rear-facing".

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply, 3 correct) A- Skin thickening B- Decreased height C- Increased Saliva production D- Nail thickening E- Decreased bladder capacity

B- Decreased height D- Nail thickening E- Decreased bladder capacity BDE

A nurse is caring for a client whose partner passed away, 4 months age. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make?

"You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling"

Name 3 signs of respiratory distress of neonates

- Retracting -Nasal Flaring -Grunting

What is the goal for interventions for the oldest-old?

-Focus on preserving the patient's functional abilities -Electronic technology -Look for simple things you can do to promote better techniques -Facilitate and encourage physical exercise -Facilitate empowerment -Safety

Name four teaching points for a client about sleep hygiene?

-Use your bedroom for sleep -Follow a regular routine -Go to bed at the same time each night -Keep the bedroom dark/cool/quiet as possible -Weighted blanket -Unable to fall asleep in 30 minutes -Get up and do something non stimulating -Use relaxation methods

Name three types of stress

Distress/Eustress External/Internal Developmental Stressors Situational Stressors Time Stressors

a 78-year-old client is newly diagnosed with diabetes. The nurse is instructing them about blood glucose testing. After the session, the client stated, "I can't be expected to remember all this stuff." The should recognize this response as most likely related to which factor?

Moderate to severe anxiety

Pt c/o : "I have felt tired during the day and cannot sleep at night." Nurse response questions: (select all that apply, 4 correct) A- "Have your working hours changed recently" B- "Do you feel confused in the late afternoon" C- "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups/ day?" D- "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E- "Tell me about any personal stress you are experiencing?"

A- "Have your working hours changed recently" C- "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups/ day?" D- "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E- "Tell me about any personal stress you are experiencing?" ACDE

A nurse caring for a 19-year-old transgender client recognizes that this client is at increased risk for which health outcomes (Select all that apply, 3 correct) A- Attempted suicide B- Healthcare provider bias C- Social isolation D- Positive body image E- Pneumonia

A- Attempted suicide B- Healthcare provider bias C- Social isolation ABC

A nurse is preparing a health promotion course for a group of middle-aged adults. Which of the following strategies should the nurse recommend? (select all that apply, 4 Correct) A- Eye examination every 1 to 3 years B- Decrease intake of calcium supplements C- DXA screening for osteoporosis D- Increase intake of carbohydrate in the diet E- Screening for depressive disorders

A- Eye examination every 1 to 3 years C- DXA screening for osteoporosis D- Increase intake of carbohydrate in the diet E- Screening for depressive disorders ACDE

The nurse writes a nursing diagnosis for a patient of "excess fluid volume." What risk factor would the nurse assess in this patient?

Renal Failure

A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply, 5 CORRECT) A- Obtain a periodic mental status evaluation B- Discuss the prevention of sexually transmitted infections. C- Regularly screen for tuberculosis. D- Provide education about drug and alcohol use. E- Teach monthly breast examinations. F- Teach about testicular exams.

A- Obtain a periodic mental status evaluation B- Discuss the prevention of sexually transmitted infections. C- Regularly screen for tuberculosis. D- Provide education about drug and alcohol use. F- Teach about testicular exams. ABCDF

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the pt to promote sleep and rest? (Select all that apply, 4 correct) A- Practice muscle relaxation techniques B- Exercise each morning C- Take an afternoon nap D- Alter the sleep environment for comfort E- Limit fluid intake at least 2 hrs before bedtime

A- Practice muscle relaxation techniques B- Exercise each morning D- Alter the sleep environment for comfort E- Limit fluid intake at least 2 hrs before bedtime ABDE

The nurse assesses the client who presents to the ED with a panic attack. Which findings should prompt the nurse to confer with the HCP about obtaining ABGs? (Select all that apply, 3 correct) A- Respirations 4- bpm B- Tingling in the fingers C- Muscle twitching D- Excess salivation E- Increased urination

A- Respirations 4- bpm B- Tingling in the fingers C- Muscle twitching ABC

Which normal conditions would a nurse expect to find when performing a physical assessment of a patient's respiratory system? (select all that apply, 3 correct) A- Slightly contoured chest with no sternal depression B- Anteroposterior diameter of the chest is less than the transverse diameter C- Quiet and nonlabored respiration occurring at a rate of 18 to 20 bpm D- Barrel chest appearance in older adults E- Bronchial, vesicular, & bronchovesicular breath sounds F- Crackles heard on inspiration

A- Slightly contoured chest with no sternal depression B- Anteroposterior diameter of the chest is less than the transverse diameter E- Bronchial, vesicular, & bronchovesicular breath sounds ABE

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation.

Alarm stage

A nurse is using an interpreter to communicate with a pt. Which of the following actions should the nurse use when communicating with a pt and family members? (Select all that apply, 3 correct) A- Talk to the interpreter about the family while the family is in the room. B- Determine client understanding several times during the conversation C- Look at the interpreter when asking the family questions D- Use lay terms if possible E- Do not interrupt the interpreter and the family as they talk

B- Determine client understanding several times during the conversation D- Use lay terms if possible E- Do not interrupt the interpreter and the family as they talk BDE

To be effective in meeting various ethnic needs, the nurse should:

Be aware of patients' cultural differences

The nurse is teaching an adolescent with asthma how to use a metered-dose inhaler. Which teaching point follows recommended guidelines?

Be sure to shake the canister before using it

The nurse is caring for older adults in a long-term care facility. What age-related alteration should the nurse consider when planning care of these patients?

Cardiac volume intolerance

The nurse is caring for a client who reports falling asleep while stopped at a red light in the car. The nurse suspects the client has obstructive sleep apnea. What assessment finding is consistent with this diagnosis?

Client startles during sleep

A nurse is planning to educate a 40-year-old female client to administer her own insulin injections. Which method would be most effective in teaching the client this skill?

Demonstrate the technique and have the client practice.

A charge nurse explains the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for young adults?

Devoting time to establishing an occupation

How can you lessen a patient's anxiety before a procedure?

Education is the number one

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

Ensure no visitors or staff enter the room for a short time period

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

Establish consistent boundaries for the toddler

A mastectomy is recommended for a 68-year-old client diagnosed with breast cancer a week ago. When approached about giving consent for the mastectomy the client says, "What's the use in trying to get rid of the cancer? It will just come back! I can't handle another thing-having diabetes is enough, besides, I'm getting old. It would be different if I were younger and had more energy. "What action should the nurse take?

Explore with the client their feelings about their health problems and proposed surgery

Which theorist believed human development is maintained by instinctual drives, such as libido (sexual instinct). aggression, and survival?

Freud

The nurse assesses a patient and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

The nurse is assessing a client who has just experienced a crisis. The nurse should first assess this client for which behavior>

Level of anxiety

Anxiety occurs in degrees, from a level that stimulates productive problem-solving to a level that is severely debilitating. At a mild, productive level of anxiety, the nurse should expect to see what cognitive characteristics of mild anxiety.

Loss of contact with reality

If an Islamic patient dies, the nurse should be aware of what religious practice.

Muslims wash the body of the patient and wrap it in white cloth with the head turned to the right shoulder

A nurse is caring for a client who states, " I wake up at night sometimes with a feeling of panic. My heart races, I breathe really hard and fast and I'm usually really sweaty." The nurse plans care knowing this client is probably experiencing which health problem?

Parasomnias

Feeling drowsy during the day of having a general feeling of malaise, having difficulty performing daily tasks, impaired cognitive processing, problem-solving, decision making, restlessness, diminished body protection, paranoia, and irritability are characteristics of what?

Sleep Deprivation

The nurse is planning care for a client experiencing stress. What area should the nurse focus on when integrating the concepts underlying the cognitive-behavioral model into the client's plan of care?

Substitution of rational beliefs for self-defeating thinking and behaving

The person with an illness rarely perceives the experience as a medial diagnosis. So how does the person describe their illness?

Terms of how it makes them feel

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

The same religious beliefs can influence individuals differently

A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" whenever the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?

Trying to increase her independence

A 5-year-old client is hospitalized and will undergo surgery. THe nurse is planning the best way to discuss the surgery experience with the client. According to the child's developmental stage, which method should the nurse choose?

Use a doll to demonstrate the surgery experience and allow to play with it

A nurse auscultates the lungs of a patient with asthma. Which lung sound is characteristic of this condition?

Wheezes

The nurse cares for a client with stress. In an ongoing assessment, the nurse should identify the client's thoughts and feelings about a situation in addition to what other factor?

Whether the client's behavior is appropriate in the context of the current situation.

A client is hospitalized with a stress-related disorder. What short-term goal for the client is most realistic? The client will:

Write a list of strengths and needs