QUIZ 2

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

Quality (Asking the client what the pain feels like is using the quality component of the PQRST mnemonic. The client might describe the pain as sharp, stabbing, dull, crushing, or throbbing. The nurse should use the PQRST mnemonic to obtain more information about the client's pain.)

A nurse is reinforcing teaching with a newly licensed nurse about the function of red bone marrow. Which of the following information should the nurse include?

Red bone marrow produces white blood cells. The nurse should include that red bone marrow produces white blood cells, red blood cells, platelets, and macrophages.

A nurse is caring for a client who has a radiation injury. Which of the following actions should the nurse take?

Remove the client's clothing.

A nurse is assisting with teaching a class about mucous membranes. The nurse should include mucous membranes are found in which of the following locations?

Respiratory tract. Mucous membranes provide a protective barrier to pathogens. They are found in the mouth, respiratory tract, gastrointestinal tract, and urinary tract.

Massage

Risk of orthostatic hypotension

respiratory depression

Side effect of opioids

Stage 2 of sleep cycle

Stage 2 is a non-rapid eye movement sleep. During stage 2 sleep, breathing slows and skeletal muscle tone begins to relax.

Stage 3 of sleep cycle

Stage 3 is the deepest stage of sleep. During stage 3 sleep, the immune system strengthens and tissue is repaired.

stage 4 of sleep cycle

Stage 4 is the dreaming stage. During stage 4 sleep, there is a loss of skeletal muscle tone and vivid, color dreams occur.

A nurse is preparing a client for a procedure. Which of the following is an acceptable identifier to use identify the client?

Telephone number.

A nurse is assessing a client following administration of an opioid narcotic. Which of the following findings indicates a decrease in the client's pain?

The client is asleep.

A nurse is assisting with teaching a client who reports insomnia. Which of the following statements should the nurse make?

The client should remove the television and work items from the bedroom to promote sleep. -The client should exercise regularly. However, the client should stop exercising at least 2 hr before bedtime to promote sleep. -The client should keep their bedroom at a cool temperature to promote sleep. -The client should limit naps to less than 30 min/day to promote sleep.

A charge nurse is preparing an in-service about communication. Which of the following information should the nurse include when discussing Newcomb's ABX model of communication?

The model examines the role communication plays in society.

A nurse is reinforcing teaching with a newly licensed nurse about the function of red bone marrow. Which of the following information should the nurse include?

The nurse should include that red bone marrow produces white blood cells, red blood cells, platelets, and macrophages.

A nurse is planning care for a client who is scheduled for extracorporeal shock-wave lithotripsy (ESWL). The nurse should plan to monitor the client for which of the following adverse effects of ESWL?

The nurse should monitor the client for bruising, swelling, pain, or numbness.

A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

The nurse should use soap and water to clean hands after providing care for clients who have C. difficile to reduce the risk of transmission of the microorganism.

A nurse is assisting with teaching a newly licensed nurse about the peripheral nervous system. Which of the following statements should the nurse make?

The peripheral nervous system regulates the body's response to external stimulus.".

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics?

They stand close to the object being moved.

A nurse is assisting with teaching a client about a polysomnography test. Which of the following information should the nurse include?

This test measures body movements during sleep. Done in a sleep disorder clinic.

A nurse is assisting with teaching a class about the physiology of sleep. The nurse should include that which of the following occurs as a result of sleep?

Transfer of memory from short-term to long-term

A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

Urinary tract infection. Incomplete emptying of the bladder can cause bacterial growth due to pooling of urine. The nurse should monitor the client for manifestations of a urinary tract infection, such as urgency, frequency, and burning during urination.

Diphenhydramine

antihistamine( like Benadryl) can cause: -Dry mouth -Hypotension -Blurred vision -Urinary retention -Tinnitus( ringing sound in the ear)

Central nervous system

brain and spinal cord. The central nervous system, rather than the peripheral nervous system, is responsible for short-term and long-term memory.

nonblanchable

discoloration of the skin that does not turn white when pressed- is one clinically important skin abnormality.

ESWL (extracorporeal shock wave lithotripsy)

electrohydraulic shock waves used to break apart calcifications in the urinary system( Kidney stones)

The muscular and skeletal systems

facilitate the motion and flexibility of the body.

Constipation Nursing Interventions

instruct/encourage diet balanced w/ lots of fiber promote adequate fluid intake encourage activity & exercise provide privacy & routinely scheduled time for defecation encourage treatment of medical causes administer stool softeners apply lubricant administer enemas digital removal sitz bath establish bowel program (suppositories/stimulation) refer to PCP for med therapies discuss med regimen drink hot liquids to stimulate peristalsis.

The Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale

is an observational scale used to monitor pain level in infants.

The Face, Legs, Activity, Cry, Consolability (FLACC) pain scale

is recommended for children from 2 months to 7 years old, and for clients who are cognitively disabled.

A Numeric Rating Scale (NRS) or a Visual Analog Scale (VAS)

is used to monitor pain level for older children and adults.

Polysomnography

measures body movements, brain activity, heart rate, snoring activity, and blood pressure to diagnose sleep disorders. Night sleep.

The skeletal system

provides protection to the internal organs, such as the brain, heart, and lungs.

Multiple Sleep Latency Test (MSLT)

test that consists of a series of short, daytime naps in the sleep lab to measure daytime sleepiness and how fast the patient falls asleep; at least 4 day naps; used to diagnose or rule out narcolepsy

Stage 1 of sleep cycle

the lightest stage of sleep. During stage 1 sleep, breathing is regular, skeletal muscle tone is intact, and the client awakens easily.

A nurse is reinforcing discharge teaching with a client about medications. Which of the following client statements indicate an understanding?

"I will store narcotic medications in the original package."

A nurse is discussing Peplau's theory of the four phases of interpersonal relationships. Which of the following statements should the nurse make?

"Orientation is the first phase and occurs when a client reaches out for help." The orientation phase of the interpersonal relationship occurs when a client makes initial contact with a nurse or provider. This contact begins the establishment of the relationship and is followed by the phases of identification, exploitation, and resolution.

A nurse is reviewing communication styles. Which of the following characteristics should the nurse identify as being exhibited by a passive communicator?

-Avoid standing up for themselves when boundaries are crossed is correct. -Respond in agreement to avoid conflict is correct.

ISBAR

-Identification(Identify yourself - name/role/location Client's details - name/gender/age) -Situation(State if the situation is urgent. Identify current symptoms and clinical needs.) -Background(Diagnosis/comorbidities/other health issues/lab results/medications/allergies.) -Assessment(Provide an interpretation or summary of what you think is going on.) -Recommendation(State a clear request with a time frame.)

A nurse is preparing to administer intravenous fluids via an infusion pump to a client. Which of the following actions should the nurse take to prevent an electrical hazard?

-Unplug the cord by grasping the plug. -Ensure the plug has three prongs. -Avoid rolling equipment over extension cords.

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event?

A client had bowel surgery and died from sepsis.

sentinel event

A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm.

Acute pain

Acute pain is anticipated and lasts less than 6 months. Examples of acute pain can include a surgical incision or an acute injury.

A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

Ask the client to sit on the edge of the bed for 2 min.

A nurse is discussing types of communication styles with a group of staff nurses. Which of the following information should the nurse include?

Assertive communicators are confident in their communications.

A nurse is preparing a poster presentation for a group of staff nurses about factors influencing communication. Which of the following factors should the nurse include when discussing cognitive factors?

Autism spectrum disorder

What do bones storage?

Calcium, phosphorus, and magnesium

Cancer pain

Cancer pain is caused by a tumor or as a result of a cancer treatment such as radiation therapy, surgical removal, chemotherapy, or infection.

Chronic pain

Chronic pain causes a progressive, persistent, pain, that lasts longer than 6 months. Examples of chronic pain can include arthritis pain, back pain, and headaches.

A nurse is assisting with teaching a class about physiological changes that occur during sleep. The nurse should include that which of the following changes occur during non-rapid eye movement sleep?

Decrease in body temperature. Body temperature, heart rate, blood pressure, and respiratory rate decrease during non-rapid eye movement sleep.

A nurse is reviewing the background of electronic health records (EHR). Which of the following institutions was the first to introduce EHRs?

Department of Veteran Affairs. -The nurse should identify that the Department of Veteran Affairs first introduced the use of EHRs into their facilities in the 1970s.

A nurse is caring for a client who reports insomnia. The nurse should monitor the client for which of the following adverse effects of sleep deprivation?

Depression Tension headaches Mood swings

A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?

Focus charting

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Give the client a long-handled sponge.(A long-handled sponge assists the client with independence in bathing.)

A nurse is preparing to change the linens on a client's bed. Which of the following actions should the nurse take?

Hold soiled linens away from the nurse's clothing.

A nurse is assisting with teaching a class about the use of pain medications to clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic?

Ibuprofen, Acetaminophen

A nurse is assisting with teaching an older adult client who has a new prescription for a pain medication. Which of the following actions should the nurse take?

Instruct the client to keep a pain diary. -The nurse should present the information at a 6th to 8th grade reading level to facilitate understanding. -The nurse should instruct the client to take the pain medication before the pain becomes severe to promote comfort. -

Peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

A nurse is reviewing the five levels of communication. Which of the following statements should the nurse identify as describing emotional communication?

It refers to the speaker's state of emotions when sending a message.

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

Lock the wheels on the client's bed. -The nurse should place the chair on the client's stronger side to decrease the risk of injury. -The nurse should lower the height of the client's bed so that the client can rest their feet on the floor and decrease the risk of injury. -The nurse should place the chair at a 45° angle or parallel to the bed to decrease the risk of injury.

A nurse risk manager is performing a facility audit to determine risks for workplace violence. Which of the following findings should the nurse identify as a risk?

Long wait times to see providers.

A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool? WHY NOT BACKGROUND? ASK PROFESSOR

Medical condition. The nurse should include the client's medical condition or diagnosis in the situation component of the ISBARR communication tool. Other findings that can be included in this component are the client's age, chief complaint, and urgent needs.

A nurse is assisting with teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem?

Memory loss. (Non-benzodiazepine hypnotics, such as zolpidem, can cause memory loss, gastric discomfort, nausea, blurred or double vision, dizziness, and hallucinations.)

A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pain?

Neuropathic pain. (Neuropathic pain is caused by damage to the somatosensory system. Examples of neuropathic pain can include phantom limb pain and diabetic neuropathy.)

Zolpidem

Nonbenzodiazepine hypnotics, such as zolpidem, can cause memory loss, gastric discomfort, and hallucinations.

A nurse is preparing to clean a client's dentures. Which of the following actions should the nurse plan to take?

Place the client's dentures on a washcloth in a sink. -The nurse should clean the client's dentures with a denture cleaner. Regular toothpaste can damage dentures. -The nurse should rinse the client's dentures in cool water. Hot water can damage dentures. -The nurse should remove the client's dentures with a dry gauze. A dry gauze allows the nurse to grasp the dentures.