PrepU questions FUNDS exam 2

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense." PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

"Let me talk to your health care provider about a condom catheter."

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "don't worry, normal for older adults" "ill refer you to a urologist who can help" "lets explore structuring activities and toileting breaks" "its best to use adult diapers"

"Let's explore structuring activities and toileting breaks."

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

check health record for provider's order

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation?

checking that the client has signed a consent form for the procedure

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?

cheese and crackers; A small protein- and carbohydrate-containing snack is effective in promoting restful sleep.

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

decreased REM sleep

The nurse is caring for a hospitalized 90-year-old client. What will the nurse include in the care plan?

decreasing environmental noise

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes:

demonstrating or pantomiming ideas to clients with hearing impairments.

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure

A client who is blind is said to be experiencing:

sensory deficit.

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?

"Can you describe the type of pain you are having?"

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that."

The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?

"Do you have the sensation to urinate?"

A nurse is conducting discharge teaching for a postoperative client prescribed oral pain medication. The client states that pain medications always causes nausea. What is the appropriate response by the nurse?

"Do you take the medication on an empty stomach?"

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

"Do you work around loud noises at work?"

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem.

The nurse is caring for a client with a diagnosis of insomnia who is returning to share the success of their sleep plan. Which statement by the client indicates that the plan was successful?

Client verbalizes feeling rested.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?

Closing the client's room door to reduce unnecessary noises

A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women?

Contract the pubic muscles for 3 seconds, then relax

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting blood flow.

A student nurse is preparing a presentation on sensory overload. What symptoms of sensory overload should the student include? Select all that apply.

Fatigue, Disorientation, Sleeplessness, Confusion. Disturbances in memory, reasoning, and problem solving, Decision making may be irrational or dysfunctional, disorientation; verbalizing disconnected thoughts; complaining of too much going on, sleeplessness, and fatigue; inability to think; and poor work performance.

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client?

The client will remain safe.

Which way can the nurse decrease the sensory deprivation that the client in isolation experiences?

Visit the client often to develop trust.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan?

altered skin integrity related to urinary bladder infection and dehydration

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects which primarynursing concern?

altered sleep pattern related to acute pain

Which client is at greatest risk of sensory overload? an 8-year-old in isolation in a private room in a hospital a 17-year-old on bed rest after a surgical procedure a 55-year-old, newly diagnosed with diabetes in a private room in a hospital an 88-year-old on a ventilator in an intensive care unit

an 88-year-old on a ventilator in an intensive care unit

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

Find a phone app that plays sounds of the city.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?

Offer client a small carbohydrate and protein snack before bedtime.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid

An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being?

Sensory overload can cause anxiety and irritability.

A nurse is assessing clients in a burn unit for sensory alterations. Which factors contribute to severe sensory alterations? Select all that apply. Sensory saturation Sensory discrepancies Sensory overload Sensory deprivation Sleep deprivation Cultural overload

Sensory overload, Sensory deprivation, Sleep deprivation

For which conditions would the nurse assess to determine if a client is suffering from sensory deprivation or overload? Select all that apply.

boredom, anxiety, thought disorganization

The nurse is counseling an older adult client. Because of the client's age, the nurse recognizes that she is at risk for macular degeneration. Which of the following is a priority nursing intervention?

Teach the client signals of serious eye problems, such as visual disturbances.

A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action?

Teach the client to perform deep-breathing and coughing exercises.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks.

The nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique?

The nurse gives the client a massage before bed.

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include:

a decrease in the deep sleep stage of the sleep cycle.

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9 a.m. and 9 p.m.

The nurse is providing client education for the parents of an obese child diagnosed with obstructive sleep apnea. What treatment measures would the nurse explain during the education session? Select all that apply. a weight loss plan treatment with intranasal antibiotics treatment with sleeping pills use of a continuous passive airway pressure (CPAP) machine counseling for depression use of a mandibular advancement device (MAD)

a weight loss plan use of a continuous passive airway pressure (CPAP) machine use of a mandibular advancement device (MAD)

The nurse should obtain a sleep history on which clients as a protocol?

all clients admitted to a health care agency

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused to time and place

Endogenous opioids such as endorphins:

contribute to analgesia.

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. cutaneous neuropathic acute chronic somatic

cutaneous acute

A client has been NPO. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

dark amber

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:

pus

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation.

What will the nurse place at the bedside of a client receiving epidural analgesia?

Ampule of 0.4 mg naloxone

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?

Newborns sleep 16 to 17 hours per day.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.

During NREM sleep, the client will exhibit

a decrease in: body temperature, pulse, blood pressure, and respirations.

The nurse is caring for a client who reports having "kidney pain from a urinary tract infection" for 3 days. How will the nurse describe this pain when reporting off via SBAR? Select all that apply. somatic visceral chronic acute neuropathic cutaneous referred

acute visceral

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as:

adaptation

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

administering backrub when client's head hurts

A 4-year-old child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6 to 8 hours per day. Based on this information, what nursing concern is applicable to this family?

altered parenting associated with failure to provide stimuli for growth

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

sleep paralysis and automatic behavior

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply. smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism exercises 30 to 60 minutes daily works 30 hours per week

smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?

stress

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber

The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing independently, drowsy, but arousable with extreme or repeated stimuli. How will the nurse document the client's level of consciousness ?

stupor

A nurse is instructing new parents on the proper sleeping position for their newborn. In what position does the nurse instruct the parents to place the newborn?

supine position

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

the client's pain based on a pain rating

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:

they may be disoriented on awakening.

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will:

urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid."

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

use caution when driving an automobile.

The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply. use of assistive devices for senses history of recent immunizations medications that may alter sensations anything interfering with sensory reception any recent changes in sensory stimulation

use of assistive devices for senses medications that may alter sensations anything interfering with sensory reception any recent changes in sensory stimulation

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision?

verbal report

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

visceral pain.

Altered sensory reception is a category of occurrences that can lead to sensory deprivation. Which scenario describes an example of altered sensory reception?

An 87-year-old woman is losing her eyesight. She is not able to leave her assisted living apartment without help. She is becoming more and more confused.

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?

Acknowledge the pain as the client reports it and administer pain medication as prescribed.

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?

1; indicates that the client is alert and awake

The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which supplies would the nurse need to gather? Select all that apply. 10-mL (milliliter) syringe Sterile specimen container Consent form Antiseptic swab Sterile gloves

10-mL (milliliter) syringe Sterile specimen container Antiseptic swab

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen

Which client could be diagnosed with insomnia?

A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m.

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan

Which situation demonstrates sensory adaptation? A client with hearing loss has learned to communicate using sign language. A client has learned to sleep through the frequent beeping of the intravenous pump. A client believes their hearing has become more acute since the loss of his vision. A client with vision loss has begun buying large-print books.

A client has learned to sleep through the frequent beeping of the intravenous pump.

Which client would be the best candidate to receive epidural analgesia for pain management?

A client recovering from recent hip replacement surgery

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso

Toddlers explore their environment by seeing, hearing, touching, tasting, and smelling. School-age children learn to make independent responses based on what is perceived through the senses. A newborn's sensory perception is very refined. Preschoolers seek out information using organized play.

A newborn's sensory perception is very refined.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? You Selected: Asking the client when he or she had last urinated

The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?

Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

Which is true regarding the normal urination?

Catheterized clients should drain a minimum of 30 mL of urine per hour.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

The health care provider tells the nurse that the older adult client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?

"How long have you experienced this pain?"

A nurse is conducting an assessment of a middle-aged client who reports difficulties with sleeping at night. Which information would the nurse correlate with the client's sleep-wakefulness pattern? Select all that apply. "I usually go to bed around 9 and get up at about 7." "I usually get up two to three times a night to urinate." "I'm always tired and feel like I don't have much energy anymore." "I like to keep a dim light on during the night in case I need to get up." "I have never tried using any medicine to fall asleep."

"I usually go to bed around 9 and get up at about 7." "I usually get up two to three times a night to urinate."

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?

"I will record the time I go to bed and how long it takes me to fall asleep."

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching?

"I will remind my family member to push the PCA pump button for me if I doze off during the day."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?

"I will use clean gloves to handle the catheter and other equipment."

A parent reports their 4-year-old child wakes up at night screaming and this occurs shortly after the child has fallen asleep. The nurse determines that the child takes a tub bath and the parent reads a story prior to bedtime at 8 p.m. What is the best response to the parent? Select all that apply. "It is common for this to occur in this age group." "Comforting your child when this occurs may help." "Put the child in your bed to sleep when this occurs." "You may find a nightlight in his room is helpful." "You will need to change your child's bedtime routine."

"It is common for this to occur in this age group." "Comforting your child when this occurs may help." "You may find a nightlight in his room is helpful."

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

A male client informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of an indwelling urinary catheter. The nurse is aware that the catheter was in place for 3 weeks prior to being removed. Which is the nurse's bestresponse to the client?

"It will take a little while for the bladder to reestablish control as the strength of the muscle improves, and an accident is not unusual."

A hospitalized client informs the evening shift nurse about not being able to sleep without a shot of whiskey each night before bed and asks if the spouse can bring in a bottle. Which is the bestresponse by the nurse?

"Let's discuss that with your health care provider."

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning."

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

"One signal of preparedness is when your child is dry for at least 2 hours."

A client has recently stopped smoking but reports having much trouble with sleep. Which response will the nurse use to explain to the client about this situation?

"Sleep problems from smoking cessation are temporary."

The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate?

"Stress causes the muscles to become tense."

The nurse is educating a client and spouse about sudden jerking that occurs during sleep. What is the most appropriate nursing response?

"Sudden twitches that occur during the early phases of sleep are common."

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?

"The CPAP assures you get enough oxygen throughout the night."

The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information? "The RAS serves to monitor and regulate incoming sensory stimuli." "The RAS allows all impulses to reach the cerebral cortex and to be perceived." "The RAS is a well-defined network that extends from the hypothalamus to the medulla." "To receive stimuli and respond appropriately, the brain can be in any state of arousal."

"The RAS serves to monitor and regulate incoming sensory stimuli."

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement?

"What makes you think the food is poisoned?"

The nurse is educating a client about nonpharmacologic measures to alleviate restless leg syndrome (RLS). Which education point(s) will the nurse include in the plan? Select all that apply. Drinking a cup of coffee before bed can help relieve the tingling sensations. Applying heat or cold to the extremity can help relieve the symptoms. An alcoholic drink is recommended before bed to relax you. Biofeedback and TENS can help you relax and relieve symptoms. Massaging the legs may relieve symptoms. A mild analgesic before bed can help relieve symptoms.

-Applying heat or cold to the extremity can help relieve the symptoms. -Biofeedback and TENS can help you relax and relieve symptoms. -Massaging the legs may relieve symptoms. -A mild analgesic before bed can help relieve symptoms.

A nurse is assessing an adult client with back pain. The client is unable to speak the dominant language. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?

0 to 10 numeric rating scale

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

Administering an oral dose of morphine to treat the client's breakthrough pain

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

Administration of 0.4 mg of naloxone

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?

Activates the receptors for the hormone melatonin

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult?

Acute confusion

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication

A client is prescribed escitalopram, diuretics, and pseudoephedrine. The client states, "I'm tired all the time." What does the nurse understand may be happening to this client?

Decrease in R.E.M. sleep due to prescribed medications

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

Decreased interest in activities, Depression, Sleeplessness

The nurse desiring to use laughter as a therapeutic modality for pain should assess for which therapeutic effects? Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure Shallow respirations Decreased heart rate

Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure

The nurse will be starting an intravenous line on a client who is hard of hearing. The nurse will implement which interventions? Select all that apply.

Ask, "May I turn down the sound on your television?", Speak directly to the client, Look at the client's face as much as practical. There is no need to speak loudly.

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?

Assess the client's vital signs and pulse oximetry.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included?

Assist the client to a normal voiding position when possible.

The nurse is working on the neurological unit and caring for Mr. Thom, a 39-year-old man who has suffered a severe head injury and is comatose. Then nurse is providing education to the family and visitors about communication with the client. What will the nurse include? Select all that apply. Assume the person can hear the conversation. Speak to the person before touching. Keep environmental noises at low levels. Talk about things that would normally be discussed. Speak loudly to be sure the client can hear the conversation.

Assume the person can hear the conversation. Speak to the person before touching. Keep environmental noises at low levels. Talk about things that would normally be discussed.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action?

Avoid massaging this area and report the finding to the health care provider.

The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. Which action(s) will the nurse take to assess the client's use of the CPAP machine? Select all that apply. Discuss the client's habit of using the CPAP. Explore the client's understanding of disinfection. Provide education about the importance of CPAP. Elicit the client's understanding of sleep apnea. Examine the fit of the mask.

Discuss the client's habit of using the CPAP, Examine the fit of the mask.

A client could experience increased urination when using which classification of medication?

Cholinergic agents

What factor has been hypothesized by researchers regarding current thoughts on sleep?

Chronic sleep deprivation is present.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. Discard used supplies. Clean each labial fold, then the area directly over the meatus. Inflate the balloon with the correct amount of sterile saline. Advance the catheter until there is a return of urine. Insert the lubricated catheter into the urethra.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting?

Coma

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

Contact the health care provider

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply.

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse?

Contact the health care provider. The nurse should contact the health care provider, as PCA therapy for pain management is contraindicated for clients with sleep apnea. This is due to the fact that oversedation in clients with sleep apnea poses a significant health risk. PCA therapy is also contraindicated in confused clients, infants and very young children, cognitively impaired clients, and clients with asthma.

What type of pain will the client experience as a result of the intervention being preformed?

Cutaneous

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

Cutaneous stimulation

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client?

Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?

Do you usually go to bed and wake up about the same time each day?

A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action?

Document the client's allodynia.

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. Dry the perineal area after urination or defecation from the back to the front. Take baths instead of showers. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse.

Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body.

factors affecting sensory stimulation

Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. The amount of stimuli different people consider optimal appears to vary considerably.

The nurse is caring for Nancy, a 45-year-old client with diabetes mellitus. She has severe neuropathy and consequently has little or no feeling in her feet and lower legs. The nurse includes which nursing interventions in the care plan related to this lack of tactile sensation? Select all that apply. Do not allow assistive devices to be used. Educate client to never go barefoot. Protect skin from temperature extremes. Perform frequent, thorough skin assessments. Assess for shoe type and correct fit.

Educate client to never go barefoot. Protect skin from temperature extremes. Perform frequent, thorough skin assessments. Assess for shoe type and correct fit.

A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client? Select all that apply. Nap frequently during the day to make up for the lost sleep at night. Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. Exercise vigorously before bedtime to promote drowsiness. Eat a small snack of protein and carbohydrate before bedtime. Discuss the use of a sleep aid with the health care provider.

Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. Eat a small snack of protein and carbohydrate before bedtime. Discuss the use of a sleep aid with the health care provider.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?

Eliminating disturbing odors with adequate ventilation

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) Encourage increased protein. Encourage the use of a sitter. Encourage deep breathing. Promote a restful environment. Play the client's favorite music.

Encourage deep breathing. Play the client's favorite music. Promote a restful environment.

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake.

An older adult client reports insomnia. Which interventions can the nurse implement to promote quality sleep for the client?

Encourage the client to empty the bladder at bedtime.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

Examine the effectiveness of the current pain regimen

The nurse is caring for Mr. Cantrell, a 69-year-old client. He has gradually lost much of the ability to hear in both ears due to working with loud machinery all of his working life. Which interventions will the nurse add to Mr. Cantrell's care plan in order to make him more comfortable with his hearing loss? Choose all that apply. Face the client; use meaningful gestures. Be aware of nonverbal communication. Decrease background noise if possible. Do not chew gum or food when speaking. Avoid verbal conversation when possible.

Face the client; use meaningful gestures. Be aware of nonverbal communication. Decrease background noise if possible. Do not chew gum or food when speaking.

The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply. Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Remove appliance faceplate by pulling appliance from skin rather than pushing. Apply a silicone-based adhesive remover by spraying or wiping as needed. Clean skin around stoma with alcohol on a gauze pad. Make sure skin around stoma is thoroughly dry by patting it dry. Apply faceplate by using firm, even pressure for approximately 60 seconds.

Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping as needed. Make sure skin around stoma is thoroughly dry by patting it dry.

Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents?

Getting the child to sleep can be difficult.

When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain?

Give the client a back rub.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone

Assessment of a client reveals that the client is experiencing sensory deprivation. Which finding would the nurse identify as a perceptual response to this situation? Select all that apply. Hallucinations Daydreaming Decreased attention span Difficulty with problem solving Belligerent behavior

Hallucinations Daydreaming

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue?

Have the client further evaluated for depression

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation.

The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply. How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain?

How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain?

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

Which is not a lifespan consideration for sleep cycles? In adolescents, there is a shift to later evening bedtime. Newborns can sleep up to 16 to 18 hours per day. By middle age, the frequency of nocturnal awakenings decreases, and satisfaction with sleep quality increases. Getting the toddler and preschooler to fall asleep is a common problem.

In adolescents, there is a shift to later evening bedtime.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

Most sedative hypnotics lose their effect after 1 or 2 two weeks of administration.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for nonrapid eye movement (NREM) sleep?

It is called slow wave sleep.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the health care provider for which intervention?

Low-flow oxygen

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings

The nurse assesses redness, drainage, and odor to the area around a client's peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings.

The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What education should the nurse provide about the complications related to OSA?

OSA contributes to hypertension and heart disease.

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?

PRN order

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

Preventing constipation

The nurse is caring for Emily, an 81-year-old client who is struggling to adapt to worsening vision as she ages. The nurse performs which interventions to assist Emily in adapting to this sensory deficit? Choose all that apply. Provide adequate lighting. Orient to person, place, and time. Provide large print books. Speak so she can observe lip movements. Make sure her glasses are available.

Provide adequate lighting, Provide large print books, make sure her glasses are available.

A new client in the medical-surgical unit reports difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nurse identifies the nursing concern of altered sleep pattern with insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this this client's nursing concern?

Provide an opportunity for the client to talk about concerns.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

A nurse is reviewing the history of an older adult who is diagnosed with presbycusis. Which finding would the nurse identify as supporting this condition? Select all that apply.

Reports that hearing difficulties are worse in a noisy environment, Reports that the difficulties are getting worse over time

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system?

Reticular activating system

The nurse completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next?

Secure the tubing of the peritoneal dialysis catheter to the client's abdomen.

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation

Which actions are performed according to guidelines for caring for visually impaired clients? Select all that apply.

Sit in the person's field of vision if he or she has partial or reduced peripheral vision, Speak in a normal tone of voice. Orient the person to the arrangement of the room and its furnishings.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness?

Somnolence

A nurse attempts to wake a sleeping client who is scheduled for tests. The client is easily aroused from sleep. Which stage of sleep is was this client most likely experiencing?

Stage II

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?

Stop the PCA pump.

A client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client?

Talk to the client in a normal tone of voice.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

The CRIES scale is appropriate for neonates (0 to 6 months)

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions?

The client drinks two glasses of water before and after sexual intercourse.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine.

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?

The client will likely not be able to sleep.

The nurse is preparing a care plan for a client with disturbed sensory perception. What would be appropriate goals for the client to achieve? Select all that apply. The client will state feeling rested after sleeping. The nurse will use a communication board when speaking with the client. The nurse will assist the client with ADLs as needed during the hospital stay. The client will develop effective communication during the hospital stay. The client will not fall during the hospital stay.

The client will state feeling rested after sleeping, The client will develop effective communication during the hospital stay, The client will not fall during the hospital stay.

A nurse uses a portable bladder ultrasound device to assess bladder volume for a client who is unable to void. Which statement accurately details information needed to interpret the results?

The device must be programmed for the biological sex of the client by pushing the correct button on the device.

The nurse is giving a back massage to a client who is having trouble sleeping. Which nursing actions are performed appropriately? Select all that apply. The nurse applies warmed lotion to client's shoulders, back, and sacral area. The nurse completes the massage with additional short, stroking movements that eventually become heavier in pressure. The nurse massages the client's shoulder, entire back, areas over iliac crests, and sacrum with light vertical stroking motions. The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks. The nurse kneads the client's skin using continuous grasping and pinching motions.

The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. The nurse applies warmed lotion to client's shoulders, back, and sacral area. The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?

They bind to opioid receptor sites throughout the CNS.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?

Thrill and bruit

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence?

Total incontinence

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice?

Urinal

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

Which of the following accurately describes senses by which individuals maintain contact with the external environment? Select all that apply. Vision Kinesthesia Smell Hearing Taste

Vision, Smell, Hearing, Taste

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?

When obtaining client vital signs

A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.

The nurse is caring for a group of clients on the acute care unit. Which client(s) will benefit from urinary catheterization? Select all that apply. a confused client that requires a sterile urine specimen to be obtained a client that is unable to mobilize to the bathroom following abdominal surgery a client that developed a urinary tract infection a client with an enlarged prostate that is unable to void a client in septic shock that is unresponsive

a client in septic shock that is unresponsive a confused client that requires a sterile urine specimen to be obtained a client with an enlarged prostate that is unable to void

A client states to the nurse during a sleep assessment that it takes her more than 60 minutes to fall asleep. The nurse documents this time period as the client's:

sleep latency.

The nurse is meeting an older adult client for the first time in their hospital room. Which of the following interventions should be a priority at this time?

asking if the client uses prescription glasses.

An older adult client has been hospitalized for 8 days following skin grafting. The nurse suspects the client is experiencing sensory deprivation. Which strategy will be most effective in this situation?

assess and reorient the client to time, place, and person as needed.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

difficulty with memory, problem solving, and task performance, inability to control direction of thought content, inaccurate perception of sights, sounds, tastes, and smells

The nurse is working on a neurological unit and a health care provider asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply.

diminished senses related to advanced age, neuropathy related to diabetes mellitus, medications that alter certain senses

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply. decreased temperature pallor (peripheral vasoconstriction) elevated heart rate elevated respiratory rate decreased blood pressure

elevated respiratory rate decreased blood pressure

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A 75-year-old client was admitted to the hospital for altered mental status. The client had been in their usual state of good health until this morning when a nurse at the long-term care facility where the client lives noticed that the client was confused. Shortly after being admitted to the hospital, the client became combative and had to be restrained. The client's bed linens have to be changed frequently because of urinary incontinence. Which nursing concern is best for this client's condition?

functional incontinence

During REM sleep, the client experiences

increases in: temperature, pulse, blood pressure, and respirations increase. the client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations.

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

intermittent urethral catheter

The nurse is discussing sleep interventions with a client. What statement made by the client indicates an understanding of sleep restriction?

limiting time in bed to actual sleep time

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

modulation

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder.

The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply. somatic visceral referred neuropathic acute

neuropathic acute

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:

oliguria

A client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:

overload.

When a person selects, organizes, and interprets sensory stimuli, the process is termed

perception.

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

perception.

The nurse is caring for a client with an amputated limb. The client reports a severe burning sensation in the amputated limb and is asking for medication to help. Which medication, if prescribed, should the nurse administer?

pregabalin

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his:

reticular activating system (RAS).

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is:

reviewing the client's sleep diary for the past 2 weeks.

The nurse is working in the intensive care unit (ICU) caring for an older adult client who has been in the unit for 2 days that is experiencing auditory and visual hallucinations. What are the most likely contributing factors related to this problem for this client? Select all that apply.

sensory overload, too much noise, sleep deprivation

A client has just been told that he has lung cancer. The health care provider then describes several potential courses of treatment to the client. When the health care provider leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply. reflex urinary incontinence urinary retention situational low self-esteem impaired urinary elimination risk for infection

situational low self-esteem risk for infection