Nursing 110 - Test 3

A nurse is assisting a client to a standing position. The client requires frequent breaks and is unable to catch his or her breath. After standing for a few seconds, the client states he or she is exhausted and needs to lie down again. Which is an appropriate priority nursing diagnosis for this client? Impaired physical mobility Activity intolerance Risk for injury Risk for disuse syndrome

Activity intolerance

A 36-year-old male has been admitted to the medical-surgical floor for 24-hour observation due to exhaustion. The client reports difficultly falling asleep and then staying asleep for the past 5 months when he started a new job working nights. In addition, he states that since his 5th child was born, it is loud in his house, causing him to not get restful sleep when he gets home from work. He states he often works 12- to 14-hour shifts and only gets about 4 hours of sleep before having to return to work, and frequently dozes off on the job. He came to the hospital because he thinks he has "narcolepsy or something." Upon further assessment, he reports being very agitated at the slightest things and that he and his wife have been fighting a lot, and the nurse notices he looks very tired with dark circles underneath his eyes. What is the objective data in this scenario that help form the nursing care plan? Admitted for exhaustion Looks tired with dark circles under the eyes Reports being very agitated Works 12 to 14 hours with only 4 hours of sleep Difficulty falling asleep

Admitted for exhaustion Looks tired with dark circles under the eyes

A client with restless leg syndrome reports difficulty sleeping. Which factors may be the cause? Select all that apply. Age Shift work Low iron levels Antidepressants Alcohol consumption

Age Low iron levels Antidepressants

The nurse is reviewing electroencephalograph results for a client who reports sleep difficulty. Which waves would the nurse expect to disappear when the client is asleep? Alpha Delta Theta Spindle

Alpha

A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss? Renin Aldosterone Erythropoietin Antidiuretic hormone (ADH)

Antidiuretic hormone (ADH)

Which are methods used to prevent orthostatic hypotension problems when clients are standing? Select all that apply. Antiembolism stockings Crutches Walkers Abdominal binders Medications

Antiembolism stockings Abdominal binders Medications

A client with irritable bowel syndrome reports excess gas after meals. Which foods should the nurse instruct the client to avoid in the diet to decrease gas production? Select All That Apply. Pasta Beans Yogurt Onions Broccoli

Beans Onions Broccoli

Which is an advantage of intermittent catheterization over indwelling catheters? Convenience to the client Decreased risk of infection Can be removed immediately and client can void normally Convenient for the nurse

Can be removed immediately and client can void normally

The nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen? Obtaining the specimen from the drainage bag Disconnecting the tubing and obtaining the specimen Inserting a new indwelling urinary catheter to obtain a sterile urine specimen Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically

Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically

Which intervention can the nurse include in the plan of care for a client in the hospital to promote sleep and rest? Clustering activities Preventing daytime naps Turning lights on for safety Keeping visitors from staying the night

Clustering activities

Which intervention can the nurse include in the plan of care for a client in the hospital to promote sleep and rest? Clustering activities Preventing daytime naps Turning lights on for safety Keeping visitors from staying the night

Clustering activities

Which is the result of the passage of stool through the colon being slowed? Diarrhea Constipation Distention Ileus

Constipation

Which symptoms characterize flatulence? Select all that apply. Cramping Abdominal distention Rectal bleeding Heartburn sensation Sharp abdominal discomfort

Cramping Abdominal distention Sharp abdominal discomfort

The nurse is performing passive range of motion for a client with osteoarthritis and feels a grating sound in the left knee. How would the nurse document this finding? Edema Friction Shearing Crepitus

Crepitus

Which physiological factors can place an 83-year-old client at risk for acute kidney injury? Select all that apply. Decline in glomerular function Loss of urinary sphincter control Arteriosclerotic blood vessel changes Decreased abdominal muscle control Consumption of large quantities of caffeine

Decline in glomerular function Arteriosclerotic blood vessel changes

During digital removal of stool, which is the most serious complication the client is at risk of developing? Bleeding Decreased blood pressure Hypertension Decreased heart rate

Decreased heart rate

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply. Leakage of urine Decreased frequency of urination Decreased volume of urine Nocturnal frequency of urine Bladder infections

Decreased volume of urine

A nurse is placing an indwelling catheter in an obese female client and realizes that the catheter is in the vagina rather than the urinary meatus. Which action should the nurse take? Remove the catheter from the vagina and again try to place the catheter. Adjust the client's position or lighting and attempt again with the same catheter. Discard the catheter, adjust the client's position and lighting, and try again with a new catheter. Discard the catheter and ask another nurse to try to place the catheter.

Discard the catheter, adjust the client's position and lighting, and try again with a new catheter.

A client reports performing intense cardiovascular workouts every day for 45 minutes. Which information should the nurse include to prevent dehydration? Select all that apply. Drink 8 ounces of fluid prior to exercise. Sports drinks provide better thirst relief. Rely on your thirst reflex to determine needs. Continue to drink water throughout exercise. Refrain from drinking excessive water after exercise.

Drink 8 ounces of fluid prior to exercise. Continue to drink water throughout exercise.

When educating student nurses on self-care and sleep hygiene, what information should be included? Fatigue can cause impaired judgment and decision making. If possible, take frequent breaks (e.g., every 1 to 2 hours) during the night shift. Be smart about your caffeine use. Use breaks and lunch hours for exercise and cardio activity. Plan rest days in between consecutive work days.

Fatigue can cause impaired judgment and decision making. If possible, take frequent breaks (e.g., every 1 to 2 hours) during the night shift. Be smart about your caffeine use.

Which describes the ability to carry out activities of daily living with vigor and alertness, without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies? Mobility Fitness Exercise Endurance

Fitness

Which type of exercise program does a nurse recommend to an older adult to prevent injury and muscle strain? Intensity Duration Flexibility Resistance

Flexibility

A client is given the instructions to avoid eating before bedtime, keep the head of the bed elevated at 30 to 40 degrees, and to avoid fatty foods, chocolate, and smoking. Which impaired digestive function is most likely for this client? Gastroesophageal reflux Decreased gastric secretions Glucose intolerance Decreased intestinal peristalsis

Gastroesophageal reflux

What is the term for the amount of blood that is filtered in a minute? Creatinine Ammonia Blood urea nitrogen Glomerular filtration rate

Glomerular filtration rate

What should the nurse instruct a group of adults regarding ways to incorporate exercise into the day? Select all that apply. Go for a walk while on break. Perform isometric exercises. Park your car at end of the parking lot. Take the stairs instead of the elevator.

Go for a walk while on break. Park your car at end of the parking lot. Take the stairs instead of the elevator.

A client presents to the clinic requesting medication to help him or her sleep. The health-care provider diagnoses the client with insomnia. Which criteria would the nurse expect to be present related to this diagnosis? Select all that apply. Happens three times a night Happens three days per week Happens for at least three months Happens when unable to sleep for three hours Happens from three causes: caffeine, smoking, or alcohol

Happens three days per week Happens for at least three months

What questions would best address sleep changes and problems when assessing a client's sleep history? Select all that apply. How often do you experience difficulty falling asleep? Do you ever experience an unpleasant creeping feeling, crawling, or tingling, relieved only by moving the legs at night? Do you snore? Do you grind your teeth while you sleep? Do you take any sleep medications or other drugs?

How often do you experience difficulty falling asleep? Do you ever experience an unpleasant creeping feeling, crawling, or tingling, relieved only by moving the legs at night? Do you snore? Do you grind your teeth while you sleep?

Which part of the brain controls circadian rhythms? Thalamus Cerebellum Pituitary gland Hypothalamus

Hypothalamus

In which sleep stage would a client's EEG show beta waves? Drowsy stage In periods of wakefulness Earlier phase of NREM When transitioning to deep sleep

In periods of wakefulness

The nurse is educating a group of teenagers regarding obtaining sufficient amounts of sleep. Which consequences of sleep deprivation should the nurse include in the presentation? Decreases risk for strokes Increases sensitivity to pain Intensifies insulin resistance Strengthens the immune system Increases the appetite and intake

Increases sensitivity to pain Intensifies insulin resistance Increases the appetite and intake

The nurse is educating a group of teenagers regarding obtaining sufficient amounts of sleep. Which consequences of sleep deprivation should the nurse include in the presentation? Select all that apply. Decreases risk for strokes Increases sensitivity to pain Intensifies insulin resistance Strengthens the immune system Increases the appetite and intake

Increases sensitivity to pain Intensifies insulin resistance Increases the appetite and intake

A client who has just changed to working third shift is concerned about getting enough sleep. What is the probable cause for this? Interrupted circadian rhythm Stress-related insomnia Asynchronous sleeping habits Insufficient melatonin production

Interrupted circadian rhythm

A client who has just changed to working third shift is concerned about getting enough sleep. What is the probable cause for this? Interrupted circadian rhythm Stress-related insomnia Asynchronous sleeping habits Insufficient melatonin production

Interrupted circadian rhythm

What is the benefit of the nurse providing a back massage instead of delegating it to a NAP? It allows fostering of the nurse-client relationship while assessing client needs. The nurse can ensure the client is responsive to treatment. The identity of the client can be confirmed without question. Clients are more apt to relax with the nurse than with a NAP.

It allows fostering of the nurse-client relationship while assessing client needs.

Which nursing interventions can help promote sleep? Select all that apply. Keep the room dim or dark. Change the linens daily or when soiled. Hold opioid analgesics before bedtime. Position the client to provide good body alignment. Turn on the television set to the client's favorite show.

Keep the room dim or dark. Change the linens daily or when soiled. Position the client to provide good body alignment.

The nurse is assessing the sleep-wake pattern of a client admitted to the hospital with a gastrointestinal bleed. Which findings would require a more in-depth sleep evaluation? Lasts for longer than 30 days Wakes up four times per night Snores about one night per week Smokes one pack of cigarettes daily Takes more than 15 minutes to fall asleep

Lasts for longer than 30 days Wakes up four times per night

The nurse is educating a client using crutches for the first time to go up and down the stairs. What is the most important aspect to include? Lead with the bad leg when going up the stairs. Navigate the stairs with someone in front of you. Use the tripod position with the crutches going up the stairs. Lead with the good leg when going up the stairs.

Lead with the good leg when going up the stairs.

The nurse is educating a client using crutches for the first time to go up and down the stairs. What is the most important aspect to include? Lead with the bad leg when going up the stairs. Navigate the stairs with someone in front of you. Use the tripod position with the crutches going up the stairs. Lead with the good leg when going up the stairs.

Lead with the good leg when going up the stairs.

What is the hormone that naturally controls sleep? Melatonin L-tryptophan Progesterone Testosterone

Melatonin

A nurse is caring for a client with type 2 diabetes mellitus who is scheduled to undergo a computed tomography (CT) scan with IV contrast of the abdomen due to suspected intestinal malignancy. Which medication should the nurse hold prior to the procedure and for 48 hours after the procedure? Insulin Diazepam Bisacodyl Metformin

Metformin

The nurse is working with a client newly diagnosed with narcolepsy. Which treatment regimen would the nurse expect to be prescribed for this client? Methylphenidate (Ritalin) Bilevel positive airway pressure Continuous positive airway pressure Set bedtime and waking time each day

Methylphenidate (Ritalin)

The nurse is caring for a client with uncontrolled type 1 diabetes mellitus and is experiencing varying blood glucose levels. Which nursing intervention should the nurse perform that may prevent sleep and rest for the client? Provide a snack every 3 to 4 hours. Administer insulin as prescribed. Administer 50% dextrose before bed. Monitor blood glucose levels during the night.

Monitor blood glucose levels during the night.

Which changes can be noted during the deepest stage of non-REM sleep? Select all that apply. Muscles relax. Heart rate lowers. Respirations decrease. Blood pressure increases. Body temperature increases.

Muscles relax. Heart rate lowers. Respirations decrease.

Which is the restful phase of sleep in which physiological function is slow? NREM REM RAS CSA

NREM

Which sleep disorder involves a person suddenly waking up thrashing about and hallucinating? Insomnia Narcolepsy Sleep apnea Night terrors

Night terrors

Which sleep disorders are considered secondary and are caused by underlying health disorders? Select all that apply. Pain Anemia Asthma Depression Hyperthyroidism

Pain Depression Hyperthyroidism

A preoperative client has not been sleeping well for years but is having even more difficulty lately due to worry about the procedure and concern about being able to receive Ambien while in the hospital. The client states, "I really can't sleep at all without it," and has been taking the medication for several years. Even though the client will receive opioid analgesics postoperatively, the physician still prescribes Ambien. What could be the reason behind this decision? Pain can cause sleep disturbances. The client needs as much sleep as possible to recover from surgery. The medications will have differing effects on the client. The client's age is a factor in sleep patterns that should not be disrupted during hospitalization.

Pain can cause sleep disturbances.

Which statement best describes parasomnia? Parasomnia is when a client has difficulty falling asleep. Parasomnias include sleep apnea and narcolepsy. Parasomnia is a pattern of waking behavior that involves sleepwalking. Parasomnia is an umbrella term that includes restless leg syndrome as a cause.

Parasomnia is a pattern of waking behavior that involves sleepwalking.

The parents of a toddler report difficulty getting their child to sleep at night. The child wants to play and not go to sleep. Which intervention suggested by the nurse would be most effective? Give the toddler melatonin prior to sleep. Plan sedentary activities the last hour before bed. Punish the child for not listening to the rules for bedtime. Feed the child a large snack 30 minutes prior to going to bed

Plan sedentary activities the last hour before bed.

Which describes the attachment of a muscle to a more stable bone? Point of origin Point of insertion Articulation Synovial point

Point of Origin

A client asks the nurse which foods would help to consume 25 to 30 grams of fiber per day. Which foods should the nurse instruct the client to include in the diet? Select all that apply. Pasta Popcorn Dried beans Applesauce Raw vegetables Whole-grain breads

Popcorn Dried beans Raw vegetables Whole-grain breads

Which condition in older men can result in impaired flow of urine from the bladder into the urethra? Renal calculi Prostatic hypertrophy Cardiovascular disorders Stroke

Prostatic hypertrophy

Which are functions of body fat? Select all that apply. Protection of vital organs Produces blood cells Essential to cell metabolism Enables nerve-impulse transmission Helps eliminate wastes

Protection of vital organs Essential to cell metabolism Enables nerve-impulse transmission

Which are ways the nurse can promote regular defecation for clients? Select all that apply. Provide privacy. Remind the client that constipation could occur if he or she does not defecate regularly. Take a matter-of-fact straightforward approach. Control odors to prevent embarrassment. Accompany the client and provide encouragement while he or she is attempting defecation.

Provide privacy. Take a matter-of-fact straightforward approach. Control odors to prevent embarrassment.

Which are common gastrointestinal symptoms suggestive of food allergy? Select all that apply. Nausea Rash around the anus Excessive gas Intestinal bleeding Severe vomiting

Rash around the anus Excessive gas Intestinal bleeding

Which interventions should the nurse include in the plan of care for a postmenopausal client with osteoporosis? Select all that apply. Refrain from cigarette smoking. Perform weight-bearing exercises. Include vitamin D and phosphorus in daily intake.

Refrain from cigarette smoking. Perform weight-bearing exercises. Include vitamin D and phosphorus in daily intake.

Which is an appropriate nursing diagnosis for a client who has had a stroke and has left-sided hemiparesis? Impaired physical mobility Sedentary lifestyle Risk for disuse syndrome Risk for injury

Risk for disuse syndrome

What priority nursing intervention does the nurse incorporate into a plan of care to promote sleep for a hospitalized client? Schedule nursing care to avoid interrupting sleep. Promote good body alignment to facilitate relaxation. Control the temperature of the room and provide good ventilation. Offer cool cloths or a back massage.

Schedule nursing care to avoid interrupting sleep.

Which neurotransmitters are related to excitatory and inhibitory sleep mechanisms? Select all that apply. Glycine Aspartate Serotonin Histamine Prostaglandins Acetylcholine

Serotonin Histamine Prostaglandins Acetylcholine

With which type of bowel diversion is the client most likely to have control over bowel elimination and not need to wear an appliance? Ileostomy Ascending colon colostomy Transverse colon colostomy Sigmoid colostomy

Sigmoid colostomy

An adolescent reports constant fatigue and an inability to stay awake in school. Which factors should the nurse assess for that could be interfering with sleep? Select all that apply. Smart phone use Drug and alcohol use Caffeine consumption Hectic work schedules School work and studying Depression, anxiety, and tension

Smart phone use Drug and alcohol use Caffeine consumption School work and studying

Which mineral can contribute to heart disease, hypertension, and stroke if consumed in large amounts? Iron Magnesium Sodium Calcium

Sodium

What is a nursing consideration for arousing a client during the (NREM) stage of sleep?

Temperature, heart rate, and blood pressure are slightly decreased.

A client blames recent weight gain on his or her metabolism. Which is the best information that the nurse can provide to the client about how metabolism works? The body converts food into complex forms of chemical energy and then into usable energy; therefore, extra food intake must have equal energy exertion in order to not gain weight. Metabolism encompasses all the ways in which the body changes and uses nutrients for vital processes and bodily functions, so metabolism is unable to cause weight gain. The metabolic process involves exerting energy from foods to provide basal metabolic rate, or energy needed for the body to sustain function at all times. The body uses metabolism to release energy, allowing us to engage in bodily functions that do not cause weight gain.

The body converts food into complex forms of chemical energy and then into usable energy; therefore, extra food intake must have equal energy exertion in order to not gain weight.

The parents of a 2-year-old child voice concern to the nurse that they are not able to toilet train the child yet. Which factors should the nurse explain to the parents that affect toilet training? Select all that apply. The child must be able to sense the urge to void. The child must be able to remove his or her clothes. The child must be able to voice the need to urinate. The child must be able to completely wipe from front to back. The child must be able to balance himself or herself on the toilet.

The child must be able to sense the urge to void. The child must be able to remove his or her clothes. The child must be able to voice the need to urinate.

Which high-amplitude brain waves found during sleep are common in children but rare in adults? Beta Alpha Theta Delta

Theta

What could potentially occur if a client takes Vitamin A, D, E, and K supplements daily? Toxicity Dehydration Impaired iron absorption Impaired metabolism

Toxicity

A client who has depression with secondary insomnia is requesting "some kind of relief" to improve his or her quality of life. What type of medication would most likely be prescribed for this client? Tricyclic antidepressant Selective melatonin agonist Benzodiazepine Barbiturate

Tricyclic antidepressant

The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply. Urine Emesis Diarrhea Nasal drainage Intravenous fluids Nasogastric drainage

Urine Emesis Diarrhea Nasogastric drainage

A 38-year-old client is asking for medication for trouble falling asleep and staying asleep. The client also feels groggy and unrested during the day. What should the nurse assess for as possible etiologies? Select all that apply. Watching TV while in bed Sleeping with smart phone nearby Caffeine consumption Current medications Exercise/activities

Watching TV while in bed Sleeping with smart phone nearby Caffeine consumption Current medications

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply. Weather Pollutants Financial strains Medical diseases Congenital disorders

Weather Pollutants Financial strains

When assessing a client for sleep disturbances, what is an appropriate question to address the sleeping environment? What room temperature do you prefer? Do you have a regular sleep schedule? What do you do to help you fall asleep? Do you sleepwalk?

What room temperature do you prefer?

When assessing a client for sleep disturbances, what is an appropriate question to address the sleeping environment? What room temperature do you prefer? Do you have a regular sleep schedule? What do you do to help you fall asleep? Do you sleepwalk?

What room temperature do you prefer?

Which are causes of obstructive sleep apnea? Select all that apply. Being overweight Enlarged tonsils Over 60-years-old Deviated nasal septum History of cigarette smoking

Which are causes of obstructive sleep apnea? Select all that apply. Being overweight Enlarged tonsils Deviated nasal septum

How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds? 30 seconds 1 minute 2 minutes 3 minutes

3 minutes

How frequently should clients with limited mobility be repositioned in bed? Every 30 minutes Every hour Every 2 hours Every 8 hours

Every 2 hours

Which is an inflammatory response to high levels of uric acid in the blood, resulting in severe pain and limited activity levels? Ankylosing spondylitis Rheumatoid arthritis Gout Osteoarthritis

Gout

Which ion controls acid-base balance? Sodium Oxygen Hydrogen Potassium

Hydrogen

Which is the most appropriate type of cane for individuals who have balance problems? Single-ended cane Curved-handle cane Multiprong cane Walker

Multiprong cane

How would the nurse assess for costovertebral angle tenderness? Inspect the urinary meatus. Auscultate over the abdominal aorta. Percuss between the 12th rib and spine. Palpate in the pubic area over the bladder.

Percuss between the 12th rib and spine.

A postoperative client has been placed on a clear liquid diet. Which item should the nurse offer the client? Popsicle Milk shake Orange juice Yogurt

Popsicle

Which type of exercises should the nurse recommend to an obese client to reduce pain and increase compliance? Select all that apply. Jogging Swimming Playing tennis Using a rowing machine Riding a recumbent bike

Swimming Using a rowing machine Riding a recumbent bike

Which type of joint is a synovial joint? The cranium The vertebrae The knee joints The pubic bones

The knee joints

. The nurse is discussing sleep patterns with a client who reports sleep disturbances. Which questions should the nurse ask the client to determine the cause of the sleep problem? Select all that apply. "What do you do for employment?" "Do you include exercise in your daily life?" "What is a typical 24-hour food intake for you?" "When does your spouse normally go to sleep?" "How many caffeinated beverages do you drink each day?"

"Do you include exercise in your daily life?" "What is a typical 24-hour food intake for you?" "How many caffeinated beverages do you drink each day?"

The nurse is discussing sleep patterns with a client who reports sleep disturbances. Which questions should the nurse ask the client to determine the cause of the sleep problem? "What do you do for employment?" "Do you include exercise in your daily life?" "What is a typical 24-hour food intake for you?" "When does your spouse normally go to sleep?" "How many caffeinated beverages do you drink each day?"

"Do you include exercise in your daily life?" "What is a typical 24-hour food intake for you?" "How many caffeinated beverages do you drink each day?"

The nurse is discussing the benefits of exercise with a client that has a history of hypertension and atherosclerosis. The client expresses hesitancy about beginning an exercise program with having heart disease. What is the nurse's best response? "Why are you hesitant to begin an exercise program?" "It is healthier for your heart to exercise than to be sedentary." "You must begin an exercise program to prevent further cardiac damage." "Let me speak to your health-care provider prior to beginning an exercise program."

"It is healthier for your heart to exercise than to be sedentary."

The nurse is caring for a client who underwent bowel surgery and returns to the floor with a nasogastric tube to low intermittent wall suction. The family questions the nurse as to why the client has the tube. What is the nurse's best response? "The tube is in place to remove secretions until the bowels begin to work." "The tube is in place in order for us to administer medications." "The tube is in place to administer tube feedings until the bowel heals." "The tube is in place to assess for gastrointestinal bleeding postoperatively."

"The tube is in place to remove secretions until the bowels begin to work."

A client asks the nurse why he or she needs to have a laxative with a strong bowel prep prior to a colonoscopy. How should the nurse respond? "I will ask the doctor to speak with you." "Your bowel needs to be completely empty in order to directly visualize your lower intestine." "Colonoscopies need to be done while your bowel is working." "Anything in your intestine could cause bleeding during the procedure."

"Your bowel needs to be completely empty in order to directly visualize your lower intestine."

How many hours of sleep per day does a newborn need? 16 to 20 10 to 11 8 to 9 7 to 8

16 to 20

Which client would most benefit from an internal fecal management system? A client incontinent of stool with a sacral decubitus ulcer A younger client diagnosed with a Clostridium difficile infection A client who requires a bowel prep for a colonoscopy procedure A client with irritable bowel syndrome that also has constipation

A client incontinent of stool with a sacral decubitus ulcer