NUR 310 Exam 2 Ch. 28, 45, and 25

An older adult client in the hospital has been deemed a risk for falls. What falls prevention measure should the nurse prioritize?

Anticipate the client's need to urinate and assist to the toilet as appropriate

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

Infection control measures supported by evidence that when implemented together improve patient outcomes are known as:

bundles

What are the states of awareness?

conscious and unconscious

The school nurse is preparing a presentation about safety promotion for middle school-aged students. Which topic will the nurse plan to include?

consistently using seat belts

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

Factors affecting sensory function and functional ability can be _______ or _______

-acute -chronic

Which statement should the nurse include in the teaching plan for a family learning about fire safety?

"Most people who die in home fires die from inhalation and not from burns."

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

"I am concerned that the small rugs in your home can be a tripping hazard."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?

"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

The nurse is evaluating risk factors for a developmentally diverse group of clients. Which client(s) is at risk for safety? Select all that apply. -A toddler allowed to crawl in a house that has not been childproofed -A machinist working in an environment with exposure to loud noises -A sales executive worried about making the yearly sales quota -An older adult client with a shuffling gait -A 42-year-old client with left-side paralysis following a stroke

-A toddler allowed to crawl in a house that has not been childproofed -An older adult client with a shuffling gait

What are examples of external sensory reception?

-Auditory -Gustatory -Olfactory -Tactile -Visual

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply. -Apply physical restraints at regular periods throughout the day. -Have facility security personnel assist when the client is agitated. -Check that all exit doorways have a STOP sign posted. -Encourage the client to walk outdoors when weather permits. -Place a bell over the client's room and other facility doors.

-Check that all exit doorways have a STOP sign posted. -Place a bell over the client's room and other facility doors.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. -Client-centered care -Teamwork and collaboration -Establishment of clinical career ladders -Revamping the licensing requirements for foreign-educated nurses -Quality improvement (QI)

-Client-centered care -Teamwork and collaboration -Quality improvement (QI)

What are the conscious states?

-Delirium -dementia -confusion -normal consciousness -somnolence -minimally conscious states -locked-in syndrome

What are examples of internal sensory reception?

-Kinesthetic -Stereognosis -Visceral

What are the 4 conditions that must be met for a sensory experience?

-Stimulus -Receptor -Impulse -Translation

A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply. -four-point soft restraints -isolation -administration of sedation -four side rails up -having a parent stay with the child

-administration of sedation -four side rails up -having a parent stay with the child

What environments might lead to sensory overload?

-admission to acute care facility -bright lights -lengthy verbal explanations before a procedure -frequent treatments and visitors -lack of sleep -pain, dyspnea or anxiety -decreased cognitive ability -nervous system disturbances or medications that stimulate arousal mechanism

What dies RAS allow you to focus on?

-allows you to focus on what you value -allows you to perceive a threat -supports you when you set goals

What are the unconscious states?

-asleep -stupor -coma -vegetative state

What are examples of reticular activating system at work?

-athletes block out the sounds of the crowd -we block out the sounds of traffic outside

What are general factors that influence functional ability and sensory function?

-developmental stage -lifestyle and environment -stimuli -social interaction -cultural factors -medications and health status

What are signs and symptoms of sensory deprivation?

-excessive yawning, drowsiness, and sleeping -preoccupation with somatic complaints -hallucinations of delusions -depression, apathy, emotional lability -decreased attention span, difficulty concentration, and decreased problem solving -impaired memory; periodic disorientation; general or nocturnal confusion

What are signs and symptoms of sensory overload?

-fatigue, sleeplessness -anxiety -increased muscle tension, irritability, and restlessness -scattered attention, racing thoughts, reduced problem-solving ability, and task performance -periodic or general disorientation

What are some examples of the "medications and health status" factor that influences sensory function?

-may be adverse affects of meds (ex- Chemo affects how things taste) -stress, mental health issues (especially depression) -level of cognitive function due to deterioration from health condition (LOC)

What environments might lead to sensory deprivation?

-private room -impaired vision &/or hearing -sensory aid not available -few visitors -mobility restrictions -isolation precautions -cultural differences

What are the 6 functions of clinical judgment?

1.) Recognize cues 2.) Analyze cues 3.) Prioritize hypothesis 4.) Generate solutions 5.) Take action 6.) Evaluate outcomes

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

Describe the 4 conditions that must be met for a sensory experience?

A stimulus is introduced to the body. Then, the receptor sends a signal to a sensory nerve where the stimulus is converted into a nerve impulse. The nerve impulse is sent to the brain where it is translated. Through this translation, we gain awareness and interpretation of the stimulus.

_________ impairment is a strong predictor of hospital outcomes.

ADL

What are the steps of the nursing process?

ADPIE -Assessment -Diagnosis -Planning -Implementation -Evaluation

The nurse is caring for a new older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

When caring for a patient who has an infection such as rubella, mumps, or diphtheria, which precaution would be appropriate?

Droplet precautions

Which of the following would be considered a risk factor within the social environment? -Sleep deprivation due to working the night shift -Drug or alcohol abuse -Exposure to excessive noise on a construction site -Non-working smoke alarm in the home

Drug or alcohol abuse

Which of the following terms refers to a disorder characterized by an altered smell perception? -Hypogeusia -Ageusia -Anosomnia -Dysosmia

Dysosmia

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength

Childproofing the home is an important safety precaution which should be initiated at the toddler stage of development. T/F

False

Factors that put children most at risk for exposure to toxic substances include dosing errors, confusing the units of medication measurement, or using medication dispensing cups incorrectly. T/F

False

Presbycusis refers to the rapid, bilateral loss of high-frequency, sensorineural hearing. T/F

False

Recent data suggest that the average baseline compliance rate for handwashing health care workers is approximately 75%. T/F

False

The Centers for Disease Control lists suicide as the number one cause of death for adolescents. T/F

False

Viruses are the most significant and most commonly observed infection-causing agents in health care institutions. T/F

False

When communicating with a patient who is unconscious, assume the person can hear you, and speak in a louder-than-normal voice. T/F

False

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should prioritize what action?

Fill out an incident report, with the goal of preventing a similar event in the future.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

Identifying systemic factors on the unit that may have contributed to the event

Which of the following potential sensory deficits may occur in patients who are undergoing chemotherapy? -Impaired taste -Impaired hearing -Impaired vision -Impaired tactile perception

Impaired taste

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

Which of the following is the most effective method used to prevent absorption of an ingested toxin? -Ingestion of activated charcoal -Induced vomiting -Syrup of ipecac ingestion -Gastric lavage

Ingestion of activated charcoal

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm.

A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

Peer pressure causes children of this age to take risks.

__________ is essential for early identification of function and sensory deficiencies

Recognition

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

Which of the following describes a sensory change related to aging that involves a loss of elasticity in the lens of the eye and a decreased ability to see up close? -Cataract -Temporal arteritis -Macular degeneration -Presbyopia

Presbyopia

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan?

Restrain the infant in a car seat.

What system controls sleeping, waking, and attention?

Reticular Activating System (RAS)

Diane Ackerman proposes that the increasing use of high-tech devices which deliver assaults on our senses every day has led to what modern phenomenon?

Sensory poverty

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying.

The leading cause of preventable injury death for infants younger than 1 is mechanical suffocation caused by what?

Soft Bedding

Which of the following states of arousal would describe a person who has extreme drowsiness but will respond normally to stimuli? -Confusion -Dementia -Somnolence -Minimally conscious

Somnolence

What is a state of unconsciousness called?

Stupor

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk gently to her.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

A health care—associated infection (HAI) refers to an infection that originates or takes place while in a health care facility. T/F

True

A person in the unconscious state of stupor can be aroused by extreme and/or repeated stimuli. T/F

True

A person may exhibit all of the same manifestations in both sensory overload and sensory deprivation. T/F

True

Falls are the most common reason for admissions to hospitals for injuries in older adults. T/F

True

Prescribing antibiotics at an appropriate dose and only when indicated can help reduce the incidence of infections such as C. Difficile and those who have developed resistance to one or more classes of antibiotics. T/F

True

Teenagers between the ages of 16 to 19 years old are three times more likely to be in a fatal crash than drivers older than age 20. T/F

True

The most common cause of legal blindness in the older adult is macular degeneration. T/F

True

Transmission-based isolation precautions are used for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. T/F

True

What is a chronic condition where there is no cognitive function but the body is still alive?

Vegetative state

What is the reticular activating system (RAS)?

a "filter" to help you focus on the most important things instead of focusing on everything happening around you

What does ADL stand for?

activities of daily living

Intimate partner violence includes physical, sexual, and/or psychological abuse which can occur in which of the following relationships? -Married couple -Dating teenagers -LGBTQ relationships

all of the above

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents

What is equilibrium?

balance

Early identification of functional and sensory deficits is link to _______ outcomes

health

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick.

Acquiring disease via a vector or fomite is an example of:

indirect contact

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching?

keeping medications in clearly labeled containers

What is the primary function of the Thalamus?

relay motor and sensory signals to the cerebral cortex.

The natural habitat of microorganisms, where growth and multiplication occur, is known as the:

reservoir

What is the optimal arousal state?

sensoristasis

What do you have if there is a decrease in or lack of meaningful stimuli?

sensory deprivation

What do you have if you are unable to process or manage the amount or intensity of sensory stimuli?

sensory overload

Following a concussion, the nurse teaches the patient to avoid all but which of the following activities? -Sleeping -Anti-inflammatories -Watching TV -Reading

sleeping

What is sensory perception?

the ability to receive sensory input and, through various physiologic processes in the body, translate the stimulus or data into meaningful information

Carriers that transmit organisms from one living thing to another, such as mosquitoes, ticks, and lice, are known as:

vectors