NURS 208 Final

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? Dyspnea Hypotension Decreased respiratory rate Decreased pulse rate

a. If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? Increase physical activities during the day. Encourage short periods of napping during the day. Increase fluids during the evening. Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? Vitamin B malnutrition Obesity Dehydration Vitamin C deficiency

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. Arrange for assessment for depression and treatment. Discourage napping during the day. Decrease fluids during the evening. Administer diuretics in the morning. Encourage patient to engage in some type of physical activity. Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

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.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. Daily mental activities Daily physical activities Morning and evening body temperature Daily measurement of fluid intake and output Presence of anxiety or worries affecting sleep Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. A patient with irritable bowel syndrome who has intractable diarrhea A patient with celiac disease not absorbing nutrients from the GI tract A patient who is underweight and needs short-term nutritional support A patient who is comatose and needs long-term nutritional support A patient who has anorexia and refuses to take foods via the oral route A patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (McClave et al., 2016; Worthington & Gilbert, 2012). PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

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.

A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. Absence of nausea, vomiting Weight gain Bowel sounds within normal range Large amount of gastric residue Absence of diarrhea and constipation Slight abdominal pain and distention

a, c, e. Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.

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 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 nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? Use warm water or air and gentle pressure to remove the clog. Use a stylet to unclog the tubes. Administer cola to remove the clog. Replace the tube with a new one.

a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.

To promote sleep in a patient, a nurse suggests what intervention? Follow the usual bedtime routine if possible. Drink two or three glasses of water at bedtime. Have a large snack at bedtime. Take a sedative-hypnotic every night at bedtime.

a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

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.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? Checking the amount of oxygen in the cylinder before using it Using a cylinder for a patient transfer that indicates available oxygen is 500 psi Placing the oxygen cylinder on the stretcher next to the patient Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

a. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? Remove the tray from the room. Administer an antiemetic and encourage the patient to take small amounts. Explore with the patient why she does not want to eat her food. Offer high-calorie snacks such as pudding and ice cream.

a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.

A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process? Stroke the underside of the patient's chin to promote swallowing. Serve meals in different places and at different times. Offer a whole tray of various foods to choose from. Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? Remove the catheter. Notify the primary care provider. Check that the airway is the appropriate size for the patient. Place the patient on his or her back.

a. When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. The nurse wets a washcloth and washes the area around the tube with soap and water. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. The nurse tapes a gauze dressing over the site after cleansing it.

a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A patient who is taking iron supplements for anemia. A patient with Parkinson's disease who is taking dopamine. An older adult taking diuretics for congestive heart failure. A patient who is taking antibiotics for an ear infection. A patient who is prescribed antidepressants. A patient who is taking low-dose aspirin prophylactically.

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.

A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI? 50.5 52.4 54.5 55.2

b. (formula for BMI is divide weight in pounds by the square of the height in inches, then multiply that by 703)

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 patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? Administering pain medication after meals. Encouraging food from home when possible. Scheduling his respiratory therapy before each meal. Reinforcing the importance of his eating exactly what is delivered to him.

b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? Circadian rhythm sleep-wake disorder Narcolepsy Enuresis Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

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 caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? Thoracentesis Pulse oximetry Diffusion capacity Maximal respiratory pressure

b. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm? Malabsorption Anemia Protein depletion Reduction in total muscle mass

b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorption. Protein depletion and malnutrition are diagnosed with serum albumin, prealbumin, transferrin, and blood urea nitrogen tests. The creatinine test may indicate dehydration, reduction in total muscle mass, and severe malnutrition.

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? Keep the room light dimmed during the day. Keep the room cool. Keep the door of the room open. Offer a sleep aid medication to patients on a regular basis.

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? The age of the patient The size of the endotracheal tube The type of secretions to be suctioned The height and weight of the patient

b. The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient's head forward. Hold the mask tightly over the patient's nose and mouth. Pull the patient's jaw backward. Compress the bag twice the normal respiratory rate for the patient.

b. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).

A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A 19-year-old patient who is a vegan An older adult patient who takes daily nutritional drinks A 43-year-old patient who takes ginkgo biloba and an aspirin daily An infant who is breastfeeding

c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.

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.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A postoperative adult An adult with COPD A teenager with cystic fibrosis A child with pneumonia

c. Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? The use of a central nervous system stimulant Continuous positive airway pressure machine (CPAP) Chronotherapy The application of heat or cold therapy to promote sleep

c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? Preparing the family for a diagnosis of insomnia and related treatments. Preparing the family for a diagnosis of narcolepsy and related treatments. Anticipating the scheduling of polysomnography to confirm OSA. No action would be taken, as this is a normal finding for hospitalized children.

c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

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 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 caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? The nurse assures that the oxygen is flowing into the prongs. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse adjusts the flow rate to 6 L/min or more.

c. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? Instruct the assistant to notify the primary care provider. Assess the patient's vital signs. Remove the tape, adjust the depth to ordered depth and reapply the tape. No action is required as depth will adjust automatically.

c. The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. "I will be careful not to shake up the canister before using it." "I will hold the canister upside down when using it." "I will inhale the medication through my nose." "I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale."

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18? Risk for Imbalanced Nutrition: More Than Body Requirements Imbalanced Nutrition: More Than Body Requirements Readiness for Enhanced Nutrition Imbalanced Nutrition: Less Than Body Requirements

d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.

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 patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? Auscultate the bowel sounds. Measure the gastric aspirate pH. Measure the amount of residual in the tube. Obtain an order for a radiographic examination of the tube.

d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.

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 patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. Teach the patient to take short shallow breaths when performing hygiene measures. Group personal care activities into smaller steps, allowing rest periods between activities.

d. For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.

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 nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? The patient consumed 75% of the liquids on her breakfast tray. The patient tells you she is hungry. The patient's abdomen is soft, nondistended, with bowel sounds. The patient reports fullness and diarrhea after breakfast.

d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the health care provider. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline.

d. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? Feed the patient solids first and then liquids last. Place the head of the bed at a 30-degree angle during feeding. Puree all foods to a liquid consistency. Provide a 30-minute rest period prior to mealtime.

d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? The patient vomits during suctioning. The secretions appear to be stomach contents. The catheter touches an unsterile surface. A nosebleed is noted with continued suctioning.

d. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A patient who has uncontrolled hypothyroidism. A patient with coronary artery disease. A patient who has GERD. A patient who is HIV positive. A patient who is taking corticosteroids for arthritis. A patient with a urinary tract infection.

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

A nurse working in a hospital setting cares for patients with acute and chronic conditions. Which disease states are chronic illnesses? Select all that apply. Diabetes mellitus Bronchial pneumonia Rheumatoid arthritis Cystic fibrosis Fractured hip Otitis media

a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time.

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A Native American patient An African-American patient An Alaska Native An Asian patient A White patient A Hispanic patient

a, c, e, f. Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

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.

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.

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. A nurse treats all patients the same whether or not they come from a different culture. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

a, d. Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping.

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 uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful? Making accurate nursing diagnoses Establishing priorities of care Communicating concerns more concisely Integrating science into nursing care

b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care.

A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply. Who is the person you depend on for emotional support? Who is the breadwinner in your family? Do you plan on having any more children? Who keeps your family together in times of stress? What family traditions do you pass on to your children? Do you live in an environment that you consider safe?

a, d. The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function.

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

a. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

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 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 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 nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? Demonstration Lecture Discovery Panel session

a. Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility? By being a role model for healthy behaviors By not requiring sick days from work By never exposing others to any type of illness By budgeting time and resources efficiently

a. Good personal health enables the nurse to serve as a role model for patients and families.

A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care? Individual and family health care needs Populations within the community Local health care facilities Families in crisis

a. In contrast to community health nursing, which focuses on populations within a community, community-based nursing is centered on individual and family health care needs. Community-based nurses may help families in crisis and work in health care facilities, but these are not the focus of community-based nursing.

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? No action is necessary as this is a normal finding during sleep. Call the primary care provider to report possible neurologic deficit. Lower the temperature in the patient's room. Awaken the patient as this is an indication of night terrors.

a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

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 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.

The nurse uses the agent-host-environment model of health and illness to assess diseases in patients. This model is based on what concept? Risk factors Demographic variables Behaviors to promote health Stages of illness

a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease.

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? Cultural imposition Clustering Cultural competency Stereotyping

a. The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

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 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.

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? Cultural assimilation Cultural imposition Culture shock Ethnocentrism

a. When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

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.

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply. A White male diagnosed with HIV An African American teenager who is 6 months pregnant A Hispanic male who has type II diabetes A low-income family living in rural America A middle-class teacher living in a large city A White baby who was born with cerebral palsy

b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs.

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.

Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply. A nurse runs an immunization clinic in the inner city. A nurse teaches a patient with an amputation how to care for the residual limb. A nurse provides range-of-motion exercises for a paralyzed patient. A nurse teaches parents of toddlers how to childproof their homes. A school nurse provides screening for scoliosis for the students. A nurse teaches new parents how to choose and use an infant car seat.

b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity.

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. The nurse reinforces the mental benefits of gaining self-control over an addiction.

b, d, f. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

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.

The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply. Preventing falls in the facility Changing a patient's oxygen tank Providing materials for a patient who likes to draw Helping a patient eat his dinner Facilitating a visit from a spouse Referring a patient to a cancer support group.

b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs; providing art supplies may help meet self-actualization needs; facilitating visits from loved ones helps meet self-esteem needs; and referring a patient to a support group helps meet love and belonging needs.

A nurse working in a primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply. Health and illness are the same for all people. Health and illness are individually defined by each person. People with acute illnesses are actually healthy. People with chronic illnesses have poor health beliefs. Health is more than the absence of illness. Illness is the response of a person to a disease.

b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential. An illness is the response of the person to a disease.

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? "This agreement forms a legal bond between the two of us to achieve your weight goals." "This agreement will motivate the two of us to do what is necessary to meet your weight goals." "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

b. A contractual agreement is a pact two people make, setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment.

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.

The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? Physiologic Safety and security Self-esteem Love and belonging

b. By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection. An example of a physiologic need is clearing a patient's airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient's family to arrange a visit.

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 on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? "I can expect my newborn to sleep an average of 16 to 24 hours a day." "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." "I will place my infant on his back to sleep." "I will not place pillows or blankets in the crib to prevent suffocation."

b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

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.

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.

The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors? The family does not have dental care insurance or resources to pay for it. Both parents work and leave a 12-year-old child to care for his younger brother. Both parents and their children are considerably overweight. The youngest member of the family has cerebral palsy and needs assistance from community services.

b. Inadequate childcare resources is a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic risk factor.

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? Long-term developmental Short-term situational Short-term motivational Long-term motivational

b. Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.

A patient in a community health clinic tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the patient exhibiting? Stage 1: Experiencing symptoms Stage 2: Assuming the sick role Stage 3: Assuming a dependent role Stage 4: Achieving recovery and rehabilitation

b. Stage 2: Assuming the sick role. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: Experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities.

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? Promoting health Preventing illness Restoring health Facilitating coping

b. Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? How do you get your medications? How does having COPD affect your lifestyle? Are you concerned about the side effects of your medications? Can you describe how you will take your medications?

b. The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? By determining the patient's motivation to learn By deciding if the learning outcomes have been achieved By allowing the patient to practice the skill he has just learned By documenting the teaching session in the patient's medical record

b. The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan.

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? Use short words and talk more loudly. Ask an interpreter for help. Explain why care can't be provided. Provide instructions in writing.

b. The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.

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 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.

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 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 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 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 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.

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

c, d, e. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

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 caring for patients in a long-term care facility uses available resources to help patients achieve Maslow's highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply. Humans are born with a fully developed sense of self-actualization. Self-actualization needs are met by depending on others for help. The self-actualization process continues throughout life. Loneliness and isolation occur when self-actualization needs are unmet. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems.

c, e, f. Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. He is aware of his surroundings at this point. He is in delta sleep at this time. It would be most difficult to awaken him at this time. This is most likely an NREM stage. This stage constitutes around 20% to 25% of total sleep. The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

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.

A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community? It meets all the needs of its inhabitants It has mixed residential and industrial areas It offers access to health care services It consists of modern housing and condominiums

c. A healthy community offers access to health care services to treat illness and to promote health. A healthy community does not usually meet all the needs of its residents, but should be able to help with health issues such as nutrition, education, recreation, safety, and zoning regulations to separate residential sections from industrial ones. The age of housing is irrelevant as long as residences are maintained properly according to code.

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? "Do you think you will be able to eat the food we have here?" "Do you understand that we can't prepare special meals?" "What types of food do you eat for meals?" "Why can't you just eat our food while you are here?"

c. Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

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 has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? Tertiary Secondary Primary Promotive

c. Giving influenza injections is an example of primary health promotion and illness prevention.

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 nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? Learning the predominant language of the community Obtaining significant information about the community Treating each patient at the clinic as an individual Recognizing the importance of the patient's family

c. In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

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 discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? Drinking a cup of regular tea at night induces sleep. Using alcohol moderately promotes a deep sleep. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Exercising right before bedtime can hinder sleep.

c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms? Jane, whose best friend had a benign breast lump removed Sarah, who lives in a low-income neighborhood Tricia, who has a family history of breast cancer Nancy, whose family encourages regular physical examinations

c. The physical dimension includes genetic inheritance, age, developmental level, race, and biological sex. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor.

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 teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? Ask Me 3 Newest Vital Sign (NVS) Teach-back method TEACH acronym

c. The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process.

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 is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. The United States has become less inclusive of same-sex couples. Cultural diversity is limited to people of varying cultures and races. Cultural diversity is separate and distinct from health and illness. People may be members of multiple cultural groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices may evolve over time but mainly remain constant.

d, e, f. A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. REM sleep constitutes much of the sleep cycle of a preschool child. By the age of 8 years, most children no longer take naps. Sleep needs usually decrease when physical growth peaks. Many adolescents do not get enough sleep. Total sleep decreases in adults with a decrease in stage IV sleep. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

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 nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family? A father, a mother, and children A group whose members are biologically related A unit that includes aunts, uncles, and cousins A group of people who live together and depend on each other for support

d. Although all the responses may be true, the best definition is a group of people who live together and depend on each other for physical, emotional, or financial support.

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.

A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health-illness continuum and the high-level wellness models? Illness as a fixed point in time The importance of family Wellness as a passive state Health as a constantly changing state

d. Both these models view health as a dynamic (constantly changing state).

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 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 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 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.

A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? Cultural imposition Clustering Cultural competency Stereotyping

d. Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.

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.

A nurse working in an "Aging in Place" facility interviews a married couple in their late seventies. Based on Duvall's Developmental Tasks of Families, which developmental task would the nurse assess for this couple? Maintenance of a supportive home base Strength of the marital relationship Ability to cope with loss of energy and privacy Adjustment to retirement years

d. The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children.

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 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 counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." "You should concentrate on other sports that you could play even with prosthesis." "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

d. This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss his feelings with the nurse or another health care professional. The other answers do not allow the patient to express his feelings and receive the counseling he needs.

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.