Semester 1 Unit 5 Exam

The majority of exudate/drainage is composed of which type of WBC during a chronic inflammatory response? (select all that apply) A. macrophages B. neutrophils C. eosinophils D. lymphocytes

A. macrophages D. lymphocytes

______ is always present with ______, but ______ is not always present with _______. Fill with: Infection Inflammation

1. Inflammation 2. Infection 3. Infection 4. Inflammation

List Maslow's Hierarchy of Needs in order.

1. Physiological 2. Safety 3. Love 4. Esteem 5. self-Actualization PSLEA Pumpkin Spice Latte Every Afternoon

Hypothermia is a body temperature below?

36.2° C / 97.2° F

What temperature in is considered normothermia (normal body temp) in Celsius and Farenhiet?

36.5° - 37.2° C 97° - 100° F

Hyperthemia is body temperature above?

37.6° C / 99.7 ° F

Normal WBC range is?

4,500 to 10,000

What tool is used to assess risk for pressure ulcers?

Braden Scale

Which type of isolation precaution requires that staff wear gloves and a gown?

Contact

c. diff, MRSA, VRE, wound infections, and eye infections would have what kind of isolation precautions?

Contact

______ is a loss of heat by air currents (caused by wind or a fan) moving across a body surface. It is accelerated by wet skin or clothing.

Convection

a loss of physical fitness A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

D. deconditioned This applies not only to an athlete who fails to maintain an optimal level of training but also to an individual who does not maintain optimal physical activity.

Pneumonia, influenza, mumps, and strep have what kind of isolation precautions?

Droplet

Sepsis has what kind of isolation precautions?

Droplet

Which nursing action reflects correct use of the Wong-Baker FACES Pain Rating Scale?

Encouraging the patient to choose a cartoon face that best represents the pain.

Besides NSAIDS, what type of drugs are used in reducing swelling and pain caused by inflammation?

Glucocorticoids (steroids that suppress the immune system, such as prednisone)

Patients who are experiencing immobility often have which of the following emotions? (Select all that apply.) Helplessness Hunger Anger Anxiety Increased communication Improved self-worth

Helplessness Anger Anxiety

What does the nurse infer if a patient scores a 2 on the Wong-Baker FACES pain rating scale?

Hurts a little bit.

What is defined as, "The invasion and multiplication of microorganisms in body tissues, which may be clinically unapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response."

Infection

Any time an infection is present, some degree of _______ will also be present.

Inflammation

What does the CDC define as, "the body's reaction to injury, irritation, or infection characterized by redness, swelling, warmth, and/or pain; caused by accumulation of immune cells and substances around the injury or infection."

Inflammation

What is defined as, "an immunologic defense against tissue injury, infections, or allergy."

Inflammation

________ is always present with infection, but can also occur in the absence of infection.

Inflammation

Pressure ulcers/injuries are the result of short-term disruption of _________.

Perfusion

_______ brings a greater volume of blood to the body surface to increase heat loss.

Peripheral vasodilation

Prolonged periods of ______ cause tissue necrosis, ulcerations, or loss of digits.

Poor perfusion

What can the nurse delegate to the CNA for a patient with skin breakdown?

Repositioning

What type of nociceptive pain is sharp and localized?

Somatic nociceptive

During which process of pain transmission does the initial stimulation of nociceptors occur? A. Transduction B. Transmission C. Perception D. Modulation

Transduction.

What is another word for verruca?

Wart

Which precaution would the nurse implement for herpes zoster? Select all that apply. a. Airborne b. Contact c. Droplet d. Standard

a. Airborne

A _______ interferes with normal cell functioning by using the host cell's metabolism for its own reproduction. a. Protozoa b. Bacteria c. Virus d. Fungus

c. Virus

Warts are a type of what? a. Parasite b. Bacteria c. Virus d. Fungus

c. Virus

The body feels fatigued when it is hot to facilitate _______, which aids in heat loss.

reduction of muscle activity

Patients who are at risk for being under-treated for pain due to inability to communicate

-cognitively impaired -infants/toddlers -anesthetized -critically ill -comatose -imminently dying

What is the normal range for circadian variation of body temperature?

0.8° - 1.0° C This is the amount it will increase or decrease from the hypothalmic "set point", which is usually 37° C / 98.6° F.

Each category of the Braden Scale receives a score ranging from __ to __, with ___ being the most ideal (no impairment).

1 to 4, 4= no impairment

Hyperpyrexia is temperature above?

41.4° C / 106.5 ° F

Which of the following patients is at higher risk for inflammatory reactions? 2-year-old girl with a healthy diet 38-year-old man who is obese 54-year-old woman in menopause 79-year-old man with diabetes

79-year-old man with diabetes

A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for developing a pressure ulcer? An 80 year-old ambulatory client with a history of diabetes mellitus An obese client who uses a wheelchair An incontinent client who has had three diarrhea stools in the past hour A 79 year-old malnourished client on bed rest

A 79 year-old malnourished client on bed rest Weighing significantly less than ideal body weight increases the number and surface area of bony prominences, which are susceptible to pressure ulcers. In addition, malnutrition is a major risk factor for pressure ulcers, from poor hydration and inadequate protein intake. Note that this is a priority question so that all of the clients are at risk for pressure ulcers. However, the question asks for the client with the highest risk.

A patient presents with a grade one pressure ulcer. The affected area of skin appears discolored. The skin remains intact, but it may hurt or itch. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Major skin and tissue injury C. Partial thickness injury D. Full thickness injury

A. Intact skin and tissue

What is important for breaking the chain of infection?

Adhering to facility PPE protocols

A negative pressure room is used for which type of isolation precaution?

Airborne

Which type of isolation precaution requires that staff wear an N95 mask?

Airborne

Which of the following is a major reason people seek health care? A. Immobility B. Infections C. Pain D. Signs of inflammation

C. Pain

Which type of isolation precaution requires that staff wear surgical masks and goggles?

Droplet

Integumentary system includes all of the following EXCEPT: A. Epidermis B. Dermis C. Subcutaneous tissue D. Hair and nails E. Tendons and ligaments F. Sebaceous glands G. Mucous membranes

E. Tendons and ligaments

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? Gait and balance Speech and hearing Mental alertness Ability to follow directions

Gait and balance

Which theory describes the origins of pain?

Gate control theory

What is normal newborn respiration and heart rate?

HR: 120-160 BPM RR: 30-60 breaths per minute

Prior to receiving anesthesia, are patients screened for hypothermia or hyperthermia?

Hyperthermia

Which condition has a higher risk of cardiac dysrhythmia, hyperthermia or hypothermia?

Hypothermia

What is the most common superficial (skin) bacterial infection?

Impetigo

Which type of fatigue is associated with mental or physical diseases?

Pathological fatigue

What is considered the most reliable indicator of pain?

Patient's report

What are the two non-physical categories tested in the Braden Scale?

Sensory perception (mental status) Nutrition

What type of onset does acute pain have?

Sudden onset

A ______ infection affects the body as a whole or has spread throughout the body.

Systemic

Sensory perception, moisture, activity, mobility, nutrition, and friction/shear are each of the 6 categories of what assessment?

The Braden Scale for pressure risk

A community health nurse is teaching a class on the best way to prevent the spread of infection, which is: a. Hand washing b. Prophylactic antibiotics c. Avoidance of hospitals d. Wearing masks

a. Hand washing

Which patient(s) may be placed on reverse isolation? Select all that apply. a. Patient on chemotherapy b. Child with Type 1 Diabetes c. Female who has just miscarried d. Transplant recipient

a. Patient on chemotherapy d. Transplant recipient

Which age group uses the FACES pain scale? a. 2 and up b. 3 and up c. 4 and up d. 5 and up

b. 3 and up

Which age group uses the numeric pain scale? a. 7 and up b. 8 and up c. 9 and up d. 10 and up

b. 8 and up

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a.First-degree skin destruction b.Full-thickness skin destruction c.Deep partial-thickness skin destruction d.Superficial partial-thickness skin destruction

b. full-thickness skin destruction

The scope of which concept maintains homeostasis by balancing heat gain and heat loss? a. Fever b. Infection c. Thermoregulation d. Inflammation

c. Thermoregulation

fever above 101, increased white blood cell count, fatigue, and generalized weakness A. systemic infection B. inflammation C. local infection D. disseminated infection

sepsis--> A. systemic infection

In times of shock, ______ can survive a temporary shunting of oxygenated blood to protect the perfusion of other organs, such as the heart and brain.

the skin

What type of pain is experienced when a cancer patient undergoes a painful cancer treatment procedure? (Acute or chronic)

The procedure is acute pain, but they are probably experiencing chronic pain from the cancer as well.

Which question asked by the nurse is most appropriate to assess the nature of the client's pain? a. "Can you describe your pain to me?" b. "Is your pain associated with movement?" c. "Can you rate your pain on a scale of O to 10?" d. "Do you notice your pain worsening with any activity?

a. "Can you describe your pain to me?"

Which of the following is an example of a nosocomial infection? a. An infection acquired by an adult from their place of employment. b. An infection acquired by an older adult from a health care facility. c. An infection acquired by a child from daycare. d. An infection acquired by a mother from her child.

b. An infection acquired by an older adult from a health care facility.

Body temp is _____ during sleep and _____ during activity.

lowest peaks

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? "Proper care of the skin is important because the immobilized patient does not want to smell bad." "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." "Proper care of the skin is important because the immobilized patient will have many visitors." "Proper care of the skin is important because the immobilized patient will be incontinent."

"Proper care of the skin is important because the immobilized patient is at high risk for breakdown."

The nurse is trying to asses for ACUTE pain in a patient with dementia what should she look for (select all that apply) A. Increased blood pressure B. Increased heart rate D. frequent positition changes C. Increased respiratory rate

A. Increased blood pressure B. Increased heart rate C. Increased respiratory rate chronic pain you wont see these changes and you must monitor your patient for subtle changes

Primary prevention for thermoregulation A. avoidance of extreme temperature change B. environmental control at home C. physical activity D. dress appropriately E. avoiding too hot or too cold of foods

A. avoidance of extreme temperature change B. environmental control at home C. physical activity D. dress appropriately

Social factors that influence access treatment to pain (select all that apply) A. income B. education C. geographic location D. gender

A. income B. education C. geographic location

An immunologic defense against tissue injury, infections, or allergy. A. inflammation B. sepsis C. chain of prevention D. antibotics

A. inflammation

What is the ideal height of elevation during the RICE method?

Above the level of the heart (Mixed info online...no more than 10" above? Some sites also say at heart level is fine.)

What elements must be present in order for infection to occur? (Select all that apply) a. pathogen b. susceptible host c. reservoir (i.e., a place where a pathogen may live and multiply) d. portal of exit from the reservoir e. mode of transmission f. portal of entry into a susceptible host

All 6 must be present

What are the risk factor(s) for altered thermoregulation? Select all that apply. a. Hormones b. Extreme temperatures c. Smoking d. Preterm birth

All of the above

Redness, rash, and hives are a visible indicator of ______ on skin.

Allergic response

The nurse is caring for a patient who sustained a hip fracture and had an open reduction and internal fixation (ORIF) of a hip fracture. The patient is complaining of pain. Which should the nurse do next? A.Reposition the patient. B. Assess the level of pain. C. Administer of pain medications before getting the patient up. D.Maintain bed rest.

B. Assess the level of pain. the nurse should first assess the pain level further before determining which intervention is needed. Repositioning the patient is an intervention and should come after assessment. Administering pain medications is an intervention and should come after assessment. Bed rest is not an intervention for pain management.

The state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes A. Pain B. Tissue integrity C. Mobility D. Inflammation

B. Tissue integrity

A newborn has purple skin and bluish hands and feet for 3-4 minutes before it takes its first breath. The nurse knows A. this is a normal finding B. this is a sign of gas a exchange problem C. this is a sign of an infection D. this is a sign of poor tissue integrity

B. this is a sign of gas a exchange problem is a normal finding..HOWEVER, should resolve immediately aka 1-2 minutes....if it doesn't resolve in 1-2 minutes this is a sign of a gas exchange problem

**Functions of the Integumentary system include all of the following EXCEPT: A. Aids in protection B. Acts as a barrier from bacteria and virus C. aids in vitamin A absorption D. Insulation E. Sensory perception F. Control of heat regulation G. Aesthetic function

C. aids in vitamin A absorption

By which method are infections commonly classified? Mode of transmission Trajectory of illness Body system affected Causative microorganism

Causative microorganism infections are classified by mode of transmission, trajectory of illness, and body system affected. However, the most common method of classification is by causative microorganism.

A peripheral tumor that causes tissue damage while growing and then presses against a nerve would be considered what type of pain?

Combination of nociceptive (tissue damage) and neuropathic (nerve pain)

Which important proinflammatory mediator is responsible for initiating neutrophil and macrophage chemotaxis to the site of tissue injury during inflammation? Leukotrienes Bradykinins Transforming growth factor Complement proteins

Complement proteins Complement proteins are very important, especially C3a, C4a, and C5a, because they initiate chemotaxis (movement) of neutrophils and macrophages toward the site of tissue injury during inflammation

_______ is a transfer of heat through direct contact of one surface to another; warmer surfaces lose heat to cooler surfaces.

Conduction

deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity A. complete immobility B. decondition C. impaired physical mobility D. Disuse syndrome

D. Disuse syndrome

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? Physiologic bonding and growth Speech and hearing development Intellectual and psychomotor function Childhood play interaction

Intellectual and psychomotor function

What is the term for conditions such as fibromyalgia, lower back pain, and myofascial pain that are not easily categorized by pain type?

Mixed pain syndromes

Which type of pain is often described as "aching", "cramping", or "throbbing" and can be caused by sunburn, surgery, or trauma?

Nociceptive pain

Which type of pain refers to normal functioning of the somatosensory system in response to unpleasant stimuli?

Nociceptive pain (No-No, Nociceptive = Normal)

What is defined as, "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

Pain

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? Vitamins and minerals Protein and calcium Fats and carbohydrates Zinc and potassium

Protein and calcium

____ occurs through a process of electromagnetic waves that emit heat from skin surfaces to the air.

Radiation

Which are characteristics of inflammation? Select all that apply. a. Redness b. Swelling c. Warmth d. Cold Sweats e. Vomiting

Redness Swelling Warmth

________ is the presence of pathogens in the blood or other tissues throughout the body.

Sepsis

A patient suffering from pain for the past couple of months visits a primary health care provider. Following the initial interview, the primary health care provider concludes that the patient is suffering from neuropathic pain. Which finding in the patient's history supports this conclusion?

Shooting, burning, shock-like sensation with painful numbness.

What are 3 risk factors for skin breakdown? (think chronic/longterm conditions - not super obvious things)

Smoking Anemia Diabetes SAD

True or FALSE: Mobility is impacted by the degree of joint freedom

TRUE

True or False The joint commission adopted the concept of pain as the fifth vital sign

TRUE

The nurse is caring for a patient who sustained a hip fracture and had an open reduction and internal fixation (ORIF) of a hip fracture. The patient will be getting out of bed for the first time postoperatively. Which should the nurse do next? Use a mechanical lift to transfer the patient from the bed to the chair. Check the postoperative orders for the patient's weight-bearing status. Avoid administration of pain medications before getting the patient up. Delegate the transfer of the patient to nursing assistive personnel (NAP).

The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The nurse should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

Goal for a patient with a ND of "Ineffective Thermoregulation": Patient's temp will be WNL after receiving antipyretic in 1 hr. True False

True

Scabies mites and lice can live off skin/hair (ie: in clothing or sheets) for how long?

Up to 2 days

What type of nociceptive pain arises from within the body cavity and is often found in the thorax, abdomen, and pelvis, but may radiate out to the back or chest?

Visceral nociceptive

Which conditions can precipitate delirium? Select all that apply. a. Infection b. Dementia c. Dehydration d. Urine retention e. Medications

a. Infection c. Dehydration d. Urine retention e. Medications

Which risk factor increases a client's risk for infection in the community? Select all that apply. a. Lifestyle b. Occupation c. Chronic diseases d. Frequent traveling e. Diagnostic procedures

a. Lifestyle b. Occupation d. Frequent traveling

Malaria, pneumocystis pneumonia, giardia, trichinosis, toxoplasmosis, ascariasis, pediculosis, and cryptosporidiosis are all examples of what? a. Parasite or protozoa b. Bacteria c. Virus d. Fungus

a. Parasite or protozoa

Who can administer pain meds? Select all that apply. a. RN b. CNA c. LPN d. UAP

a. RN c. LPN

What color is a biohazard container? a. Red b. Blue c. Yellow d. Green

a. Red

Upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. Which type of pain would the client experience? a. Visceral pain b. Somatic pain c. Referred pain d. Intractable pain

a. Visceral pain

What populations are at a higher risk for developing an infection? Select all that apply. a. Young children b. Young adults c. Pregnant women d. Older adults

a. Young children c. Pregnant women d. Older adults

A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication? a. "Antibiotics will decrease the pain at the site." b. "An antibiotic helps to kill the infection causing the inflammation." c. "An antibiotic inhibits cyclooxygenase, an enzyme in the body." d. "Antibiotics will reduce the patient's fever."

b. "An antibiotic helps to kill the infection causing the inflammation." Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

What primary prevention technique is appropiate for thermoregulation? a. Limiting oral fluid intake b. Adequate clothing and shelter c. Ice baths d. Genetic testing

b. Adequate clothing and shelter

For which illness should airborne precautions be implemented? a. Influenza b. Chickenpox c. Pneumonia d. Respiratory syncytial virus

b. Chickenpox Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

Which information would the nurse include when educating a group of daycare workers on infection control guidelines? Select all that apply. One, some, or all responses may be correct. a. Child pick-up b. Cleaning toys c. Hand hygiene d. Food preparation e. Medication administration

b. Cleaning toys c. Hand hygiene d. Food preparation

An adult presents to the emergency department with signs and symptoms of an infection. What is the nurse's Priority action? a. Apply cool compresses to head neck and axillae b. Collect a specimen for culture and sensitivity c. Administer antibiotics as prescribed by physician d. Wrap patient in a bear hugger blanket

b. Collect a specimen for culture and sensitivity

Which is an example of a primary level of prevention for Covid-19? a. Respiratory therapy b. Covid-19 vaccine c. At-home rapid testing d. Mechanical ventilation

b. Covid-19 vaccine

A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome

b. Nociceptive pain Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output

b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission e. Administration of intravenous fluids f. Strict monitoring of intake and output Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

world wide spread of a disease a. epidemic b. pandemic c. outbreak d. chain of infection

b. pandemic

Which practical response would the nurse provide a sexually active female client who is upset with her diagnosis of gonorrhea and asks the nurse, "'What can I do to prevent getting another infection like this?" a. "Douche after every sexual intercourse." b. "Avoid engaging in sexual behaviors." c. "Insist that your partner uses a condom." d. "Use a spermicidal cream with sexual intercourse."

c. "Insist that your partner uses a condom."

A ______ can cause immediate disease or remain relatively dormant for years. a. Protozoa b. Bacteria c. Virus d. Fungus

c. Virus

The nurse palpates swollen nodes in a patient's neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse's best action? a. Advise patient this finding is normal. b. Review patient's thyroid lab work. c. Perform deep tendon reflexes. d. Notify the healthcare provider.

d. Notify the healthcare provider. The nurse should notify the healthcare provider for further evaluation. Palpation is indicated to assess for the presence of lymphadenopathy, thyroid nodules or goiter. These findings could implicate the need to test further for cancer, thyroid disease or infection. These conditions should be ruled out by the healthcare provider. Thyroid nodules or changes in size indicate the need for further assessment of the thyroid. Deep tendon reflexes are part of a neuro-muscular examination and are not directly related to cervical node enlargement.

Cool ambient air is inhaled and warm air is exhaled. In this way, respiration aids in ______.

heat reduction/loss

Which step of the nursing process involves maintaining a safe environment?

Implementation

The client is one day post-op following a colon resection and there is an order to assist the client to walk in the hallway at least three times while awake. When the nurse delegates this task to the unlicensed assistive personnel (UAP), which instruction by the nurse is most appropriate? "Apply a gait belt around the client's waist if the client reports feeling dizzy." "Allow the client to sit on the side of the bed before assisting the client to stand and walk." "When assisting the client, be sure to ask about the intensity of the pain." "Have the client stand for at least two minutes before starting to walk."

"Apply a gait belt around the client's waist if the client reports feeling dizzy."

**( lewis readings) The nurse is teaching a group of clients about skin cancer. Which client statement indicates the need for further education about reducing the risk of skin cancer? "I wear sunglasses with ultraviolet protective lenses." "I only tan in the controlled setting of a tanning booth." "I found a sunscreen with a sun protective factor of 30." "I make sure to come inside between noon and 2 pm."

"I only tan in the controlled setting of a tanning booth." Tanning booths and sun lamps are no safer than the natural sun in terms of cellular damage and potential for developing skin cancer. The other self-help measures have positive effects on reducing the chance of damage from ultraviolet rays.

What term is used to describe the most severe form of fatigue? What key symptom is present?

-Exhaustion -Impaired functional status

What are 3 techniques for prioritizing patient needs?

1. Actual nursing diagnosis before risk 2. ABCs 3. Maslows

1. _______ is a situation in which there are more cases of an infectious disease than is normal for the population or geographic area. 2. _______ is a worldwide incidence of disease.

1. Epidemic 2. Pandemic

Match the following: 1.Common cold → 2.Osteomyelitis → 3. HIV/AIDS→ chronic infection acute infection latent infection

1.Common cold → acute infection 2.Osteomyelitis → chronic infection 3. HIV/AIDS→ latent infection

What is the ideal amount of time and frequency for icing a sprain during RICE protocol?

10 minutes every 2-3 hours Icing too long can cause additional tissue damage.

How long must an infection be present for it to be considered chronic?

12 weeks

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (select all that apply): A. Applying over-the-counter lotions to skin that is not broken B. Assisting the client with frequent turning to prevent pressure ulcers C. Covering the client who complains of being cold with more blankets D. Placing a sterile gauze pad over broken skin to contain drainage. E. Assessing a patient complaining of an itching rash.

A, B, C, D: All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

Function of joint (select all that apply) A. Provide stability to bones B. Allow for skeletal movement C. supports and protects tissues and internal organs D. Allow for skeletal position to carry out desired action

A. Provide stability to bones B. Allow for skeletal movement D. Allow for skeletal position to carry out desired action skeletal function -->. supports and protects tissues and internal organs

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? A. Reposition every 2 hours. B. Measure the size of the reddened area. C. Massage the area to increase blood flow. D. Evaluate the area later to see if it is better.

A. Reposition every 2 hours The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

Which term is used to describe pain duration? ( select all that apply) A. Transient B. Stabbing C. Achey D. Brief

A. Transient D. Brief

**which patients are at risk for impaired mobiltiy A. a patient taking corticosteroid B. an elderly adult C. post menopausal women D. Pt who has left sided weakness after a stroke E. A young athletic male

A. a patient taking corticosteroid..causes thinning of the bones B. an elderly adult ....at greatest risk C. post menopausal women D. Pt who has left sided weakness after a stroke

The nurse knows range of motion is important to prevent (select all that apply) A. contracture B. infection C. stiffening of the joint D. inflammation

A. contracture C. stiffening of the joint

The most common manifestations of musculoskeletal impairment include A. pain B.weakness C. deformity D. limitation of movement E.abnormal bruising F.stiffness G. joint crepitation (crackling sound)

A. pain B.weakness C. deformity D. limitation of movement F.stiffness G. joint crepitation (crackling sound)

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.

ANS: A Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of these prescribed collaborative interventions will the nurse implement first? A. Wrap the ankle and apply an ice pack. B. Administer naproxen (Naprosyn) 500 mg PO. C. Give acetaminophen with codeine (Tylenol #3). D. Take the patient to the radiology department for x-rays.

ANS: A Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives that are appropriate for this patient with the family.

ANS: C, D, F The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to A. elevate the left leg. B. splint the lower leg. C. obtain information about the tetanus immunization status. D. check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

Which type of pain is clearly linked to a specific event or injury? (Acute or chronic)

Acute

What are the most common dermatologic conditions seen in the ER?

Acute skin infections (caused by bacteria, fungi, viruses, or live arthropods)

Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self-management and alternative strategies? A. Body alignment and superficial heat and cooling B. Patient-controlled analgesia (PCA) pump C. Neurostimulation D. Peripheral nerve blocks

Answer: A Rationale: Body alignment and thermal management are examples of nonpharmacological measures to manage pain. They can be used individually or in combination with other nondrug therapies. Proper body alignment achieved through proper positioning can help prevent or relieve pain. Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort. PCA, neurostimulation, and peripheral nerve blocks are not totally self-managed or alternative therapies, because they are used under the direction of medical professionals.

Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. Pain should be reassessed at which minimum interval? A. With each new report of pain B. Before and after administration of narcotic analgesics C. Every 10 minutes D. Every shift

Answer: A & B Rationale: Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. At a minimum, pain should be reassessed with each new report of pain and before and after administration of analgesics.

Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes? A. Using a stationary exercise bicycle and free weights and attending a spinning class B. Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy C. Drinking chamomile tea and applying icy/hot gel D. Receiving acupuncture and attending church services

Answer: B Rationale: Mind-body therapies are designed to enhance the mind's capacity to affect bodily functions and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Although getting exercise, drinking chamomile tea and applying gels, and receiving acupuncture and attending church services may be beneficial, they are not classified as mind-body therapies in combination as specified in these answer choices.

A 65-year-old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of? A. Neuropathic pain B. Nociceptive pain C. Chronic pain D. Mixed pain syndrome

Answer: B Rationale: Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as dull or aching, and it is poorly localized. Neuropathic pain is described as shooting, tingling, burning, or numbness that is constant in the extremities, as in diabetic neuropathy. Chronic pain lasts longer than 30 days and is characterized by a disease affecting brain structure and function, such as chronic headaches or open wounds. Mixed pain syndromes are caused by different pathophysiological mechanisms such as a combination of neuropathic and nociceptive pain; this occurs in syndromes such as sciatica, spinal cord injuries, and cervical or lumbar spinal stenosis.

Postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course, unless contraindicated? A. Antihistamine B. Local anesthetic C. Opioids D. Nonsteroidal anti-inflammatory drug (NSAID)

Answer: D Rationale: Unless contraindicated, all surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course. Opioid analgesics are added to the treatment plan to manage moderate-to-severe postoperative pain. A local anesthetic is sometimes administered epidurally or by continuous peripheral nerve block.

A 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items near the bed and trying to get out of bed. Which intervention would be most appropriate? Arrange for a sitter to stay with the client Frequently remind the client to stay in bed Request an order for wrist restraints Request an order for antianxiety medication

Arrange for a sitter to stay with the client The plan to use safety protective devices such as wrist restraints should be rethought with a review of other safe actions. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These should be provided by the facility in the event the family cannot do so. This client who has a lung infection and productive cough needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

*Why is the older population at risk for chronic pain (select all that apply) A. ability to tolerate pain increases B. frequent recipients of surgical procedures C. More likely to suffer from conditions such as DJD and arthritis D. unable to verbalize pain E. part of the aging process F. increase risk of falls

B, C, D, F -Chronic pain is NOT a normal part of aging -ability to tolerate pain decreases -Suffer from many conditions associated with pain→ ( arthritis, changes in spine, musculoskeletal disorders) -Frequent recipients of surgical procedures -Increase risk of falls and trauma -Under-treatment of pain → unable to verbalize pain due to cognitive impairment or may be reluctant to report pain

*A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? A. Stay with the patient and offer reassurance. B. Administer the prescribed PRN oxygen at 4 L/min. C. Check the patient's legs for swelling or tenderness. D. Notify the health care provider about the symptoms.

B. Administer the prescribed PRN oxygen at 4 L/min. The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained

The nurse is obtaining a history from a patient in pain. Which question asked by the nurse will give the most information about the patient's pain? A. How long have you had this pain? B. Can you describe your pain? C. How much medication do you take for the pain? D.How many times a day do you take medication for the pain?

B. Can you describe your pain? because pain is a subjective experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses.

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? A. Apple B. Custard C. Popsicle D. Potato chips

B. Custard Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.

An elevation in body temperature due to a change in the hypothetical set point A. Hyperthermia B. Fever C. Hyperpyrexia D. Normothermia

B. Fever

Who is at greatest risk for impaired skin integrity: A. Malnourished B. Infants C. Older adults D. Active children

B. Infants→ diaper rash due to incontinence

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A. Local response. B. Systemic response. C. Infectious response. D. Acute inflammatory response.

B. Systemic response. The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

(SKILLS) A patient who has bilateral wrist restraints complains of numbness and tingling in his/her left hand. The nurse notices the patient's left hand is pale and cool to touch ..what should the nurse do next? A. get an order from the provider to take restraints off B. Take the restraint off immediately C. Loosen restraint D. Nothing...the patient is most likely lying

B. Take the restraint off immediately Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the restrained extremity.

an inability to move A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

B. immobility

The nurse is caring for a patient who will be discharged with a pain management plan following a fracture to the forearm. Which of the following should the nurse instruct the patient to do first when in pain? A. Try not to take your medications until you pain level is at an 8. B. Take your pain medications when your pain level is at a 3 C. Try repositioning your arm and applying ice before taking medications. D. Keep the hand immobile to prevent pain.

C. Try repositioning your arm and applying ice before taking medications. Nonpharmacological measures may prevent the need for medications and may be all that is necessary for proper management. A pain level of an 8 is difficult to manage. Patients should consider taking pain medications when their pain level is under 5 to gain better control over the pain. Elevating the shoulder would be uncomfortable for the patient and this position may increase pain.

Which information will the nurse include when discharging a patient with a sprained wrist from the emergency department? A. Keep the wrist loosely wrapped with gauze. B. Apply a heating pad to reduce muscle spasms. C. Use pillows to elevate the arm above the heart. D. Gently move the wrist through the range of motion.

C. Use pillows to elevate the arm above the heart. Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? A. White blood cell (WBC) count of 8000/ìL; temperature of 101 F B. White blood cell (WBC) count of 4000/ìL; temperature of 100 F C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4 F D. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8 F

C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and elevated temperature are indicators of infection.

What is the term for normal transduction of pain sensation by nociceptors?

Eudynic pain

The nurse is caring for a patient who has a suspected fracture. Which of the following assessments is most important for the nurse to perform first? Elevate the extremity. Splint the suspected injury Check the pulses Verify all immunizations.

Check the pulses

Cancer pain from tumor growth and osteoarthritis pain from joint degeneration would be considered what type of pain? (Acute or chronic)

Chronic - they are longterm and the result of underlying medical conditions

______ physical mobility describes a state in which a person has a limitation in physical movement but is not immobile.

Impaired

What does NANDA define as "limitation in independent, purposeful movement of the body or of one or more extremities."

Impaired physical mobility

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? A. Fever and chills B. Increased blood pressure C. Increased respiratory rate D. General malaise and fatigue

D. General malaise and fatigue An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well."

During which process of pain transmission does an opioid analgesic medication inhibit pain by affecting central mechanisms? A. Transduction B. Transmission C. Perception D. Modulation

D. Modulation

A client with quadriplegia is placed on a tilt table daily. The client asks why the angle of the head of the table is gradually increased. How should the nurse respond? A. It facilitates turning. B. This prevents pressure ulcers. C. It promotes hyperextension of the spine. D. This limits loss of calcium from the bones.

D. This limits loss of calcium from the bones. During prolonged inactivity, bone resorption proceeds faster than bone formation, and lack of therapeutic weight bearing on bone results in demineralization. A tilt table provides gradual progressive weight bearing, which counters these effects. Lateral turning is possible and necessary if a client is immobile, but a tilt table does not make this possible. The tilt table is used for scheduled periods in physical therapy. The nursing care required to prevent pressure ulcers must be consistently and frequently performed throughout the day and night. The tilt table does not cause hyperextension of the spine; the spine remains in functional body alignment.

Impaired bed, wheelchair, standing, transfer, and walking mobility are all types of what?

Impaired physical mobility (classified by NANDA)

Which of the following nursing interventions would a nurse be expected to do when caring for a client with syphilis? A. collects health information and a sexual history B. inquires about the client's allergy history C. inform the client that notification of the sexual partner by the department of public health is important for his or her evaluation and treatment. D. All of the above

D. all of the above Explanation: When caring for a client with syphilis, the nurse collects health information and a sexual history, inquires about the client's allergy history in anticipation of antibiotic treatment, and informs the client that notification of the sexual partner by the department of public health is important for his or her evaluation and treatment.

describes a spread of infection from an initial site to other areas of the body A. systemic infection B. Infection C. chain of prevention D. disseminated infection

D. disseminated infection

*A 5-year-old by with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After toughing the blocks, she rubs her nose with her hand. The mode of transmission is represented by: A. The 5-year-old boy B. The unvaccinated teacher's helper C. The hand-to-nose contact D. The unwashed math blocks

D: The boy has the flu and sneezes into his hand while at school. When he works with the math blocks, he leaves the flu virus on the toys. The teacher's helper picks up the virus with the blocks. When the parent touches her nose with her hand, the virus enters the susceptible host. The blocks act as the mode of transmission. The boy carries the pathogen, and his sneeze is the portal of exit. The teacher's helper is the susceptible host. The hand-to-nose contact is the portal of entry

What is the sliding board and sheet used for?

Decreasing friction

A _____ infection is one that has spread from an initial site to other areas of the body.

Disseminated

The term "impaired skin integrity" applies to which layers of the skin?

Epidermal and dermal (superficial layers only, does not apply to deeper tissue damage)

What does hyperpyrexia mean?

Extremely high body temp (above 41.5 C/106.7 F)

True or false: A patient who is unconscious can still experience pain

FALSE Pain is a conscious experience that requires an awareness and sensation via an intact nervous system.

TRUE or FALSE: UTI is an example a systemic infection

FALSE it is a local infection NOTE: elderly have weakened immune system and a UTI can very easily become sepsis

TRUE or FALSE : Patients with deeply pigmented skin, skin changes may only be present in fingernail beds

False deeply pigmented patients skin changes can be present in the fingernail beds, lips, mucous membrane of the mouth, underside of hands, and conjunctiva

Generalized weakness and reduced capacity to maintain performance are the two defining characteristics of which concept?

Fatigue

What is defined as, "distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion that is not proportional to recent activity and interferes with usual functioning."

Fatigue

Which condition involves lavage with fluids as treatment, hyperthermia or hypothermia?

Hypothermia (warmed internal fluids via IV to raise body temp?)

What 3 illnesses require airborne precautions?

Measles Tuberculosis Varicella (herpes zoster/chickenpox/shingles) Think: Live on AIR with MTV

Which theory states, "pain is the output of the neural network that is genetically determined and modified by the sensory experience"?

Neuromatrix theory

Postherpetic neuralgia, diabetic neuropathy, phantom pain, complex regional pain syndrome, trigeminal neuralgia, and poststroke pain are examples of what type of pain?

Neuropathic

What type of pain is described as "burning", "shooting", or "sharp"?

Neuropathic

What type of pain is pathologic?

Neuropathic

What type of pain may be indicated by edema, changes in blood flow, allodynia, hyperalgesia, and hyperpathia?

Neuropathic

An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis (OA) pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which actions or activities? a. Pilates, breathing exercises, and aloe vera b. Guided imagery, relaxation breathing, and meditation c. Herbs, vitamins, and tai chi d. Alternating ice and heat to relieve pain and inflammation

Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

The nurse is caring for a patient who will be discharged following a fracture to the forearm. Which of the following should the nurse include in the discharge instructions? Keep the left shoulder elevated on a pillow or cushion. Keep the hand immobile to prevent soft tissue swelling. Call the health care provider if numbness of the hand occurs. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.

Numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. Inflammation is a common primary or secondary finding among conditions leading to changes in mobility, from an underlying autoimmune condition to a traumatic injury. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. Elevating the shoulder would be uncomfortable for the patient and this position may increase pain.

Which demographic has the highest risk for fatigue?

Older adults (due to greater occurrence of underlying health conditions)

How long must pain be present for it to be considered "chronic"?

Over 3 months (and may last for years)

What is described as, "Whatever the person experiencing it says it is, existing whenever he says it does."

Pain

____ is the evaporation of moisture from the skin surface, used as a method of heat reduction.

Perspiration

Which type of fatigue occurs when there is an imbalance between physical, cognitive, and emotional activity, with the restorative actions such as sleep and diet?

Physiological fatigue

What nutrient is best for impaired tissue integrity? (ie: healing after surgery)

Protein

What intervention is used within the first 48 hours of injury to minimize swelling, thus preventing additional damage to tissues caused by the swelling itself?

RICE: Rest Ice Compression Elevation

A nurse is treating a patient with a sprain using the RICE method. The patient begins complaining that his toes feel cool and tingly. What could this indicate?

The compression wrap is too tight

What is defined as, "The state of structurally intact and physiologically functioning epithelial tissues such as the integument and mucous membranes."

Tissue integrity

What happens physiologically when where is inflammation in the body caused by an injury? (2)

Vasodilation Increased perfusion to area

Which statement made by the client indicates understanding after teaching about measures to decrease the risk for antibiotic-resistant infections? Select all that apply. a. "I should wash my hands frequently." b. "I should skip doses when I am completely well." c. "I should avoid taking antibiotics to treat the common cold." d. "I should save unfinished antibiotics for later emergency use." e. "I should avoid taking antibiotics without asking the primary health care provider."

a. "I should wash my hands frequently." c. "I should avoid taking antibiotics to treat the common cold." e. "I should avoid taking antibiotics without asking the primary health care provider."

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a. "Patients with impaired bed mobility have an increased risk for pressure ulcers." b. "Patients with impaired bed mobility like to have extra visitors." c. "Patients with impaired bed mobility need to have a mechanical soft diet." d. "Patients with impaired bed mobility are prone to constipation."

a. "Patients with impaired bed mobility have an increased risk for pressure ulcers." Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" How should the nurse respond? a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." b. "That is correct, because the face and arms are exposed more often to the sun." c. "That is not correct. Melanoma occurs on the top of the head in men but is rare in women." d. "That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

Which patient requires most immediate intervention? a. An 81 yo male, who is immunocompromised with a fever b. A 28 yo female who has just given birth to her first baby c. A 49 yo male complaining of pain in his right foot d. A 15 yo female with a rash on her left arm

a. An 81 yo male, who is immunocompromised with a fever

An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse's first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record. c. Assess the patient's blood pressure and pain level. d. Start a second intravenous line with a large bore catheter.

a. Call the rapid response team to care for the patient immediately. After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response b. Indicates that the patient has an infection at the site of the wound c. Is destroying healthy tissue d. Results from ineffective cleansing of the wound area

a. Contains the materials used by the body in the initial inflammatory response Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.

The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion d. Increased calcium deposition in the bones

a. Demineralization, calcium loss Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

A patient with chronic kidney disease is most likely to complain of which symptom? a. Fatigue b. Thirst c. Constipation d. Excess bleeding

a. Fatigue Erythropoietin is produced by the kidneys. A patient with chronic kidney disease produces less erythropoietin, resulting in anemia and fatigue as a common symptom. Thirst, or polydipsia, is a common sign of hyperglycemia and diabetes which can lead to chronic kidney disease. Constipation is not a common symptom of chronic kidney disease. Excessive bleeding can result from a decrease in platelets and clotting factors that are produced by the liver, not the kidneys.

The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) a. Feeling tired upon awakening b. Chronic migraines c. Tenderness under the jaw d. 5 episodes tonsillitis/past year e. Swollen, painful knees

a. Feeling tired upon awakening c. Tenderness under the jaw d. 5 episodes tonsillitis/past year e. Swollen, painful knees The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted). The fatigue significantly interferes with daily activities and work. The individual concurrently has four or more of the following eight symptoms: -Post exertion malaise lasting more than 24 hours -Unrefreshing sleep -Significant impairment of short-term memory or concentration -Muscle pain -Multi-joint pain without swelling or redness -Headaches of a new type, pattern, or severity -Tender cervical or axillary lymph nodes -Frequent or recurring sore throat

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? a. Hand washing before and after providing client care b. Cleaning all equipment with an approved disinfectant after use c. Wearing personal protective equipment (PPE) when providing client care d. Using medical and surgical aseptic techniques at all times

a. Hand washing before and after providing client care

A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours c. Phenergan 25 mg IM q 6 hours d. Tylenol 325 mg q 6 hoursN

a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

A 19-year-old male has sustained a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Visceral pain c. Eudynic pain d. Nociceptive pain

a. Neuropathic pain Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients withneuropathic pain use very distinctive words to describe their pain, such as "burning", "sharp", and "shooting". Visceral pain arises from the body cavities and responds to stretching, swelling and decreased oxygen levels. Eudynic pain refers to the normal transmission of pain via nociceptive receptors. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping or throbbing.

The nurse assesses the patient and notes all of the following. Which of the findings indicates systemic manifestations of inflammation? (Select all that apply.) a. Oral temperature 38.6C/101.5F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0-10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL X 10^9/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."

a. Oral temperature 38.6C/101.5F d. WBC 20 cells/McL X 10^9/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days." Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

The registered nurse (RN) asks a client to rate their pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which steps by the nursing student would be included in a physical assessment for pain? Select all that apply. a. Palpating for tenderness b. Observing nonverbal cues c. Inspecting any areas of discomfort d. Noticing if the pain is localized or radiates e. Noticing if the client gives nonverbal signs of pain

a. Palpating for tenderness c. Inspecting any areas of discomfort

_______ generally infect individuals with compromised immune responses and are spread by the fecal-oral route by ingesting food or water that has been contaminated. a. Parasite or protozoa b. Bacteria c. Virus d. Fungus

a. Parasite or protozoa

The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) a. Parents of a newborn b. Adolescent with anorexia c. 25-year-old pregnant female d. Grandmother who takes mile walks e. Businessman who consumes six cups coffee/day

a. Parents of a newborn b. Adolescent with anorexia c. 25-year-old pregnant female e. Businessman who consumes six cups coffee/day Physiologic causes of fatigue include: protein-calorie malnutrition, excessive physical activity, sleep deprivation, excessive caffeine or alcohol use, and pregnancy. Parents of a newborn are likely experiencing sleep deprivation. A patient with anorexia is likely not consuming adequate amounts of protein. Consumption of six cups of coffee/day is considered excessive. A mile walk is an appropriate exercise for an older adult and not considered excessive physical activity.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication? a. Prolonged stress response and a cascade of harmful effects system-wide b. Large tidal volumes and decreased lung capacity c. Decreased tumor growth and longevity d. Decreased carbohydrate, protein, and fat destruction

a. Prolonged stress response and a cascade of harmful effects system-wide Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

Which is a clinical finding for hypothermia? a. Red, sweaty skin b. Decreased respiration c. Low pulse rate d. Shivering

a. Red, sweaty skin

What is the priority nursing action for a patient suspected to be hypothermic? a. Remove cold wet clothing b. Hydrate with IV fluids c. Bathe patient with hot bath d. Offer a hot beverage, such as coffee or tea

a. Remove cold wet clothing

Maintaining the body at a constant 98°F defines which concept? a. Thermoregulation b. Infection c. Inflammation d. Sepsis

a. Thermoregulation

The nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions? a. They keep the child away from uninfected people. b. The infectious process is interrupted as quickly as possible. c. The child is protected from contracting a secondary infection. d. They prevent the development of a hospital-acquired infection.

a. They keep the child away from uninfected people.

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender

a. Uninsured or underinsured status c. High cost of medications d. Inadequate nutrition Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.

The occupational health nurse is making rounds in a factory. Which employees need further education about energy conservation strategies? (Select all that apply.) a. Workers reaching up to high shelf often to obtain cleaning supplies b. Workers bending over to lift boxes onto conveyer belt c. Workers who have delegated out parts of their activities d. Workers standing for long periods e. Workers standing at desks at waist level

a. Workers reaching up to high shelf often to obtain cleaning supplies b. Workers bending over to lift boxes onto conveyer belt d. Workers standing for long periods e. Workers standing at desks at waist level The employee health nurse should provide teaching to employees about energy conservation strategies to protect workers from job-related injuries. These strategies include: placing frequently used items within reach; using proper body mechanics (not bending over and straining the back); and standing for long periods of time. Delegating parts of activities is an appropriate energy conserving strategy. When standing is necessary, it is important that desks or tables are at waist level of the employee to prevent excess reaching or straining.

A patient has been recently diagnosed with chronic fatigue syndrome and asks the nurse about the cause of this illness. What is the nurse's best response? a. "The provider will be able to tell you when the lab results are back." b. "An exact cause may not be determined, but a treatment plan will be discussed." c. "Stress is the main cause; a referral to a counselor may be helpful." d. "This is considered a psychiatric illness requiring behavioral medicine."

b. "An exact cause may not be determined, but a treatment plan will be discussed." Chronic fatigue syndrome is considered an illness with an unknown etiology. There are no specific lab results that reveal chronic fatigue syndrome. Stress and mental illnesses may be contributing factors, but are not classified as exact causes of chronic fatigue syndrome.

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient? a. "Don't eat with the other students." b. "Avoid sharing razors and other personal items." c. "Have a complete blood count (CBC) checked monthly." d. "Disinfect showers and bathroom floors weekly after use."

b. "Avoid sharing razors and other personal items." Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won't relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

Which information would the nurse teach the parent of an infant who is at risk for infections? a. "You must avoid placing the infant in bright sunlight." b. "Breast-feeding will provide protection against bacteria." c. "Use soy-based infant formulas to help prevent infection." d. "The infant will be less susceptible to infections later in life."

b. "Breast-feeding will provide protection against bacteria."

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

b. "I don't bother with sunscreen on overcast days." The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

The registered nurse (RN) is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect? a. "I should wash my hands with alcohol based antiseptic." b. "I should use the cotton swab placed on the table." c. "I should wash my hands before touching the wound." d. "I should wear gloves before touching the site of injury."

b. "I should use the cotton swab placed on the table."

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response? a. "Use ice only when the ankle hurts." b. "Ice should be applied for 15-20 minutes every 2-3 hours over the next 1-2 days." c. "Wrap an ice pack around the injured ankle for the next 24-48 hours." d. "Ice is not recommended for use on the sprain because it would inhibit the inflammatory response."

b. "Ice should be applied for 15-20 minutes every 2-3 hours over the next 1-2 days." Ice is used on areas of injury during the first 24-48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2-3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response? a. "Your iron level is low. This is known as anemia." b. "Your immobility in the hospital is known as deconditioning." c. "Your poor appetite is known as malnutrition." d. "Your medications have caused drug induced weakness."

b. "Your immobility in the hospital is known as deconditioning." When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in this patient's situation.

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

A _______ causes cellular injury by releasing exotoxins (enzymes) or endotoxins (part of its own cell wall). a. Protozoa b. Bacteria c. Virus d. Fungus

b. Bacteria

Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C-diff), Vancomycin-resistant Enterococci (VRE), Escherichia coli (E. Coli), Tuberculosis, Gonorrhea, Diphtheria, and Strep are all examples of what? a. Parasitic infections b. Bacterial infections c. Viral infections d. Fungal infections

b. Bacterial infections

The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem? a. Fatigue b. Bradypnea c. Hypertension d. Fall risk

b. Bradypnea Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to bradypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.

Which of the following actions can RN delegate for patient with fever to a UAP? a. Administer antipyretic b. Check vitals c. Provide pt with ice bath d. Assess wound for signs of infection

b. Check vitals

Which are treatment related causes of fatigue? (Select all that apply.) a. Blood transfusion b. Chemotherapy c. Radiation therapy d. Surgery e. Side effects of medications

b. Chemotherapy c. Radiation therapy d. Surgery e. Side effects of medications Cancer treatments, such as chemotherapy and radiation, commonly cause fatigue. A risk of any surgery is blood loss, which can possibly lead to fatigue if the hemoglobin and hematocrit drop significantly. Fatigue is a side effect of many medications. A blood transfusion is more likely to lead to increased energy versus fatigue as the hematocrit and hemoglobin levels would be expected to rise with the transfusion.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

b. Decreasing pruritus Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self-reporting tool is best for the nurse to utilize? a. Multidimensional Assessment of Fatigue (MAF) b. Fatigue Severity Scale (FSS) c. Brief Fatigue Inventory (BFI) d. Multidimensional Fatigue Inventory (MFI)

b. Fatigue Severity Scale (FSS) The FSS was developed for patients with multiple sclerosis and lupus. The MAF was designed for arthritis patients and is also used in cancer patients and those with chronic pulmonary disease. The BFI is used for cancer patients. The MFI is used with various patient populations, including cancer, chronic fatigue syndrome, and COPD.

What is always present with infection, but can also occur without it? a. Injury b. Inflammation c. Fever d. Immunity

b. Inflammation

Which newborn should the nursery nurse identify as being at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished

b. Low birth weight Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well-nourished infant is not at significant risk.

A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient's expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy. c. Chamomile tea and IcyHot gel. d. Acupuncture and attending church services.

b. Music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy. Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind's capacity to affect bodily function and symptoms.

What is the most appropriate measure for the nurse to use when assessing core body temperature? a. Oral temp b. Rectal temp c. Temporal Thermometer scan d. Utilize a tempanic membrane sensor

b. Rectal temp

What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor

b. Rectal thermometer The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the park

b. Shopping at an indoor mall Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

Which conclusion would the nurse make regarding the client's response to pain medication when a client using a pain scale of 1 to 10 rates the pain as an 8 before receiving an analgesic and a 7 after being medicated? a. The client has a low pain tolerance. b. The medication is not adequately effective. c. The medication has sufficiently decreased the pain level. d. The client needs more education about the use of the pain scalle.

b. The medication is not adequately effective.

The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client's prescription for morphine: 2 mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse's lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first? a. Determine the documented time of the last administration of pain medication. b. Verify that the written prescription matches the administration record. c. Encourage nonpharmacological measures initially to relieve the pain. d. Explain that the primary nurse will be back from lunch in a few minutes.

b. Verify that the written prescription matches the administration record.

The nurse is teaching a patient how to use a cane with a two point gait.. The nurse will explain that the cane should be: a. used on and moved with the strong side b. used on strong side and moved with weak side c. used on and moved with weak side d. used on weak side and moved with strong side

b. used on strong side and moved with weak side

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. "The coating on these medications is irritating to my intestines." b. "I need a more immediate response from my medications than can be obtained from enteric coated medications." c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." d. "I don't need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks."

c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a. "When traveling outside of the country, I need to be sure that I receive appropriate vaccinations." b. "Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance." c. "If I don't feel sick, then I don't have to worry about transmitted diseases." d. "I need to be sure to have good hygiene practices when traveling in crowded planes and trains."

c. "If I don't feel sick, then I don't have to worry about transmitted diseases." People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

c. "Monitor spots for color change." The ABCDE method (check for asymmetry, border irregularity, color variation, diameter and evolving) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response? a. "Walk at least 5 miles every day for exercise." b. "Wear proper fitting shoes to prevent tripping." c. "Talk with your physician about a calcium supplement." d. "Stand up slowly so you don't feel faint."

c. "Talk with your physician about a calcium supplement." Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100%

c. 90%

Which client has a higher risk for contracting the human immunodeficiency virus (HIV) infection? a. A client who is involved in mutual masturbation b. A client who undergoes voluntary prenatal HIV testing c. A client who shares equipment to snort or smoke drugs d. A client who engages in insertive sex with a noninfective partner

c. A client who shares equipment to snort or smoke drugs

A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing? a. Influenza b. Mononucleosis c. Acute renal failure d. Pneumonia

c. Acute renal failure The patient's symptoms are most congruent with dehydration. Hypovolemia, due to dehydration, can lead to decreased perfusion to the kidneys resulting in acute renal failure. Influenza symptoms include headache, fever, body aches, and fatigue. Mononucleosis can manifest as severe fatigue. Pneumonia presents with cough, respiratory distress, and decreases in oxygen saturation.

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

c. Apply a thin coat to affected areas; avoid the face and groin. The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

Which category of isolation would the nurse implement for a client who is positive for Clostridium difficile? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective environment

c. Contact precautions

The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute

c. Early stage acute Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

Which is the most appropriate nursing diagnosis for a preterm infant under a warmer with a temp of 96.6°F? a. Risk for infection b. Fluid volume deficit c. Ineffective thermoregulation d. Hypothermia

c. Ineffective thermoregulation

Which of the following is NOT a sign that characterizes inflammation? a. Pain b. Swelling c. Infection d. Impaired Function

c. Infection

Which criteria would the nurse consider when determining if an infection is a health care-associated infection? a. Originated primarily from an exogenous source b. Is associated with a medication-resistant microorganism c. Occurred in conjunction with treatment for an illness d. Still has the infection despite completing the prescribed therapy

c. Occurred in conjunction with treatment for an illness

While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a. Bacterial b. Fungal c. Parasitic d. Viral

c. Parasitic Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes

c. Physical agility Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

The way an infectious agent enters a new host is called: a. Mode of transmission b. Susceptible host c. Portal of entry d. Reservoir

c. Portal of entry

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a. Host b. Mode of transmission c. Portal of entry d. Reservoir

c. Portal of entry Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment

c. Protection from excessive ultraviolet (UV) exposure Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

A nurse and CNA are caring for a client at risk for skin breakdown which action performed by the CNA would require immediate action by the nurse? a. CNA assists client while consuming high protein snack b. Turning client every two hours c. Putting multiple briefs on to keep bed dry d. Keeping sheets wrinkle free to prevent pressure ulcers

c. Putting multiple briefs on to keep bed dry

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill

c. Red, sweaty skin With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

What would be considered secondary level of prevention for infection? a. Antibiotic prescription b. Handwashing c. Sputum culture d. Vaccinations

c. Sputum culture

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A b-hemolytic streptococci c. Staphylococcus aureus d. E. Coli

c. Staphylococcus aureus Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

HIV, Hepatitis A-E, HPV, SARS, and Ebola are all examples of what? a. Parasite or protozoa b. Bacteria c. Virus d. Fungus

c. Virus

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate? a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions." The Wood's light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. "Patients must have a trapeze over the bed to move properly." b. "Patients should move themselves in bed to prevent immobility." c. "Patients should always have a two-person assist to move in bed." d. "Patients must be moved correctly in bed to prevent shearing."

d. "Patients must be moved correctly in bed to prevent shearing." Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

d. Apply sunscreen 30 minutes prior to exposure. Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

Which intervention would the nurse implement when a client's intravenous cannula insertion site has become red, swollen, and warm to the touch with purulent drainage also noted? a. Temporarily slow the infusion rate to a "keep vein open" rate. b. Elevate the extremity slightly above the level of the client's heart. c. Frequently apply cold and warm compresses to the site. d. Clean the site with alcohol, remove the cannula, and save for culture.

d. Clean the site with alcohol, remove the cannula, and save for culture.

In an otherwise healthy individual _____ do not cause disease and are contained by the body's natural flora. a. Parasite or protozoa b. Bacteria c. Virus d. Fungus

d. Fungus

Tinea pedis, candidiasis, histoplasmosis, lobo mycosis, cryptococcosis, aspergillosis, and coccidioidomycosis are all examples of what? a. Parasite or protozoa b. Bacteria c. Virus d. Fungus

d. Fungus

Mobility for the patient changes throughout the lifespan. What is the term that best describes this process? a. Aging and illness b. Illness and disease c. Health and wellness d. Growth and development

d. Growth and development Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don't always affect mobility.

Which age group uses the NIIPS, CRIES, and FLACC pain scales? a. Older adults b. Adolescents c. Adults d. Infants

d. Infants

Wound assessment findings including purulent drainage with a foul odor indicate what? a. Inflammation b. Localized fever c. Autoimmune response d. Infection

d. Infection

Based on the significant effects of chronic idiopathic fatigue, what is the nurse's priority assessment? a. Cholesterol level and lipid profile b. Creatinine and BUN levels c. Memory loss testing d. Mental health evaluation

d. Mental health evaluation Fatigue does not cause death or organ failure, but mortality from suicide was higher than the general population in patients with chronic idiopathic fatigue. Therefore a mental health evaluation is a priority assessment. Cholesterol and lipid levels are indicative of heart disease. Creatinine and BUN levels are indicators of kidney function. Memory loss is not a significant effect of chronic fatigue.

Which assessment finding in a client who had a history of chicken pox and arrived at the hospital complaining of itching and deep pain on the skin helps confirm the diagnosis? a. Red, moist, irritated skin b. Red-colored raised rash with pustules c. Sore-looking raised bumps on the skin d. Multiple lesions in a segmental distribution on the skin

d. Multiple lesions in a segmental distribution on the skin

A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse's best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.

d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates. Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

Which similar exemplar should the nurse consider when planning care for a patient with hypothermia? a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity

d. Prematurity Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

d. Remove wet clothes. The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

Which precaution would the nurse consider the priority action for decreasing the risk of a client developing a hospital-acquired infection? a. Droplet b. Contact c. Airborne d. Standard

d. Standard

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? a. All nursing functions will be completed by discharge. b. All invasive intravenous lines will remain patent. c. The client will remain awake, alert, and oriented at all times. d. The client will be free of signs and symptoms of infection by discharge.

d. The client will be free of signs and symptoms of infection by discharge.

In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. The type of cells that are being utilized by the body to attack an infection. d. The specific type of pathogen that is causing an infection.

d. The specific type of pathogen that is causing an infection. People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) Uninsured or underinsured status Easy access to health screenings High cost of medications Inadequate nutrition Mostly female genderinfection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

d. Turning the patient at least every 2 hours The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

Which nursing action is effective in controlling the spread of infection for an infant with diarrhea? a. Wearing a gown and gloves during care b. Allowing only registered nurses to give direct care c. Restricting visitors to the infant's immediate family d. Washing hands before and after contact with the infant

d. Washing hands before and after contact with the infant

Which pain scale would the nurse use when assessing a 4-year-old child? a. CRIES b. FLACC c. Numerical d. Wong-Baker

d. Wong-Baker

Standard precautions mean we treat every patient like they are _____. a. family b. dirty c. equal d. infectious

d. infectious

Name the categories and correlating number ranges for Braden Scale scoring.

≤ 9 Severe 10-12 High 13-14 Moderate 15-18 Mild

a state or quality of being mobile or movable A. mobility B. Immobility C.Impaired physical mobility D. deconditioned

A. mobility

A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The nurse should be sure to include which statement when teaching the client about managing this disease? "Continue to get yearly tuberculin skin tests." "Continue to take your medications even when you are feeling fine." "Follow up with your primary care provider in three months." "Isolate yourself from others until you are finished taking your medication."

"Continue to take your medications even when you are feeling fine." The client with TB needs is to understand the importance of medication compliance, even when the client is no longer having any symptoms. TB treatment usually requires a combination of medications with treatment for at least six months. Stopping treatment or skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks after therapy begins. Once clients no longer have a productive cough, they are not considered contagious.

The nurse is discussing dietary intake with an adolescent who has acne. What is the most appropriate statement by the nurse? "Do not use caffeine in any form, including chocolate." "Good nutritional habits promote healthy skin." "Decrease fatty foods from your diet." "Increase your intake of protein and vitamin A."

"Good nutritional habits promote healthy skin." The exact cause of acne is not known, but genetics and hormones (androgens) play a role. Stress, picking or squeezing blemishes and harsh scrubbing can make acne worse. While poor nutrition may make acne-prone teens more susceptible to breakouts, chocolate or greasy foods don't cause acne. Vitamin A helps regulate the skin cycle, but too much can lead to toxic side effects. Teens should simply eat an age-appropriate, well-balanced diet.

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? A. "Can you describe the pain?" B. "Where exactly do you feel the pain?" C. "Which activities make the pain worse?" D. "What other discomfort do you experience?"

"What other discomfort do you experience?" Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

Healing depends on (select all that apply) A. re-injury B. renewed inflammation C. diet low in protein D. immune system strength

A. re-injury B. renewed inflammation D. immune system strength

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply): A. A cleansing wound B. Managing pain C. Applying a dry sterile dressing D. Using cold water in the bath

A, B: Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to (select all that apply): A. Wear sunglasses B. Drink plenty of water C. Eat plenty of foods high in vitamin K. D. Apply sunscreen 30 minutes prior to exposure

A, D: Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

A nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when she states: A. "I need to avoid getting infections because they will increase the immune response in my body, which can make SLE worse." B. "I need to be sure to take all the available immunization to keep from getting sick." C. "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D. "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."

A. "I need to avoid getting infections because they will increase the immune response in my body, which can make SLE worse."

Who are at risk for impaired skin integrity select all that apply A. 45 y/o female receiving radiation therapy due to thyroid CA B. 78 y/o obese male who has pedal edema and consumes a low protein diet C. 25 y/o light skin female who does not wear sun screen daily with family hx of skin CA D. 55 y/o male with controlled diabetes who maintains regular physical activity E. 88 y/o female who is bed bound and is turned every 3-4 hours

A. 45 y/o female receiving radiation therapy due to thyroid CA B. 78 y/o obese male who has pedal edema and consumes a low protein diet C. 25 y/o light skin female who does not wear sun screen daily with family hx of skin CA E. 88 y/o female who is bed bound and is turned every 3-4 hours (* pt should be turned every 1-2 hours)

Histamine produces which important effects during acute inflammation? (Select all that apply.) A. Increases vasodilation B. Enhances vascular permeability C. Promotes T lymphocyte proliferation D. Activates neutrophils E. Mediates early inflammation

A. Increases vasodilation B. Enhances vascular permeability C. Mediates early inflammation Histamine is an important proinflammatory mediator released by mast cells. Similar to serotonin, histamine increases vasodilation, enhances (increases) vascular permeability, and mediates the early acute inflammatory response. Option C is incorrect because interleukin-1 promotes lymphocyte proliferation. Option D is incorrect because platelet-activating factor activates neutrophils.

A nurse is caring for an immobile patient. Which of the following are consequences of immobiltiy that she should monitor? (select all that apply) A. Orthostatic hypotension B. Constipation C. Skin break down D. Contracture of joints E. Diarrhea F. Crackles in lung sounds

A. Orthostatic hypotension B. Constipation C. Skin break down D. Contracture of joints F. Crackles (indicative of atelectasis or pneumonia)

A client you are caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be your best response? A. People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." B. He is most likely immunosuppressed from poor nutrition C. He's skin integrity has been compromised due to the foley catheter D. He is most likely immunosuppressed from his disease process or its treatment

A. People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." Explanation: Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment, may have incisions or invasive equipment (e.g., intravenous lines) that compromise skin integrity, or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Although all answers are correct, the most complete answer is A

Function of the skeletal system include all of the following expect: A. acts as the structural foundation for the body B. leverage to move body parts C. supports and protects tissues and internal organs D. attachment sites for ligaments E. stores calcium and vitamin E F. production center for red blood cells

A. acts as the structural foundation for the body B. leverage to move body parts C. supports and protects tissues and internal organs D. attachment sites for ligaments F. production center for red blood cells E. incorrect ...its stores calcium not vitamin e

Musculoskeletal system includes all the following except: A. bones B. joints C. epidermis D. muscle

A. bones B. joints D. muscle

Which statement are true about the Braden scale (select all that apply) A. screens for skin breakdown for patients in the hospital B. The higher the score the higher the risk for pressure sore development C. sensory perception, moisture, activity, mobility, nutrition, friction and shear are all assessed D. Is a primary prevention tool

A. screens for skin breakdown for patients in the hospital C. sensory perception, moisture, activity, mobility, nutrition, friction and shear are all assessed D. Is a primary prevention tool ( *pp says secondary? book says primary) -The lower the score the higher the risk for pressure sore development -Scoring: 19-23 - not at risk 15-18 - preventative interventions 13-14 - moderate risk 10-12 - high risk 6-9 - very high risk

The nurse is teaching a class of junior high school students about infection control through effective hand washing. The nurse knows that students need further teaching when one states: A. "Hand sanitizer works just as well as washing with soap and water." B. "If I sing the song 'happy birthday' twice through while scrubbing my hands, that should be long enough." C. "I need to read the label on the hand sanitizer to be sure that its at least 60% alcohol." D. "We should all wash hands before eating lunch."

A: Hand sanitizer does not work as well as soap and water, because it is not effective against all pathogens or in all situations. For example, hand sanitizer should not be used when hands are visibly dirty. Repeating the song "Happy Birthday" twice takes about 20 seconds, which is how long hands should be rubbed together with soap. Hand sanitizer needs to be at least 60% alcohol to be effective. Hand washing before eating is recommended by the Centers for Disease Control.

The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? Administering two antituberculosis drugs Aminoglycoside antibiotics High doses of B complex vitamins An anti-inflammatory agent

Administering two antituberculosis drugs In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different antitubercule medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid.

The nurse observes a physician leave the room of a patient in isolation for Clostridium difficile (C. difficile). The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which of the following actions should the nurse take? A. Nothing.. alcohol-based hand sanitizer kills C. diff B. Ask the physician to wash her hands with soap and water C. report this to upper management D. ask him to put gloves on before seeing the next patient

B. Ask the physician to wash her hands with soap and water Explanation: C. difficile is resistant to alcohol-based and other hand sanitizers; therefore physicians should be instructed to wash their hands with soap and water. The nurse could report the observation to the infection control department, but that does not address the immediate concern of the physician contaminating other patients. There is no need for the room door to be closed. The nurse must take action to ensure the safety of other patients.

The inflammatory process is an anticipated response to tissue injury that produces which desirable outcomes? (Select all that apply.) A.Initial death of tissues B. Eradication of dead tissue C.Formation of scar tissue D. Acute inflammation E. Chronic inflammation

B. Eradication of dead tissue D. Acute inflammation Inflammation is a normal and protective response to injury. Four outcomes are possible, two of which are desirable: acute inflammation and eradication of dead tissue. This process returns tissues to their previously uninjured state. The formation of scar tissue occurs when damaged cells cannot be adequately repaired. This is not the most desirable outcome. Chronic inflammation results when tissue destruction continues and is not a desirable outcome. Initial death of tissue leads to death of the host, a very undesirable outcome.

In regards to the urinary system, a patient who is immobile is at risk for all of the following EXCEPT: A. Renal calculi B. Incontinence C. Urinary stasis D. Infection

B. Incontinence

The nurse teaches a premenopausal obese client about strategies to prevent osteoporosis. Which strategy identified by the client indicates that the teaching is effective? A. Starts a rapid, strict weight-reduction diet B. Joins a tennis league and practices every day C. Takes 1200 International Units of vitamin D a day D. Signs up for a swimming class three times a week

B. Joins a tennis league and practices every day High-impact exercises (e.g., tennis, running, aerobics, dancing) are best for building bone mass. Weight loss should be slow and reasonable; restricting calories promotes production of the hormone leptin, which stimulates bone loss. The recommended intake of vitamin D for adults younger than 50 years of age (premenopausal women) is 800 International Units; 1200 mg is the recommended daily dose of calcium for adults older than 50 years of age (postmenopausal women). Signing up for a swimming class three times a week may promote overall health and vigor, but it will not increase the strength or mass of bone.

A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. A. Mosquito bites B. Sharing syringe needles C. Breastfeeding a newborn D. Kissing the infected partner E. Anal intercourse

B. Sharing syringe needles C. Breastfeeding a newborn E. Anal intercourse Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or kissing.

The nurse is developing a teaching a plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. The infected area should be covered with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

B. The infected area should be covered with a clean, dry bandage. Rationale A. The client should shower rather than take a tub bath using an antibacterial soap. B. The infected area should be covered with a clean, dry bandage to prevent the spread of infection. C. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. D. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. The nurse knows the scar tissue results from: A. Optimal functioning of the inflammatory process after injury B. Fibrous tissue replacing damaged tissue when injury is extensive C. The development of chronic inflammation D. A surgical incision

B: Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nurse assistant indicates that she understands the instruction when she agrees to (select all that apply): A. Bathe and dry the skin vigorously to stimulate circulation B. Keep the head of the bed elevated 3 degrees. C. Offer nutritional supplements and frequent snacks D. Turn the patient at least every 2 hours

C, D: The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? A. "Your primary healthcare provider must have forgotten to prescribe it." B. "Your condition is not severe enough to have physical therapy approved." C. "Your joints are still inflamed, and physical therapy can be harmful." D. "Physical therapy is not helpful for persons who suffer from RA."

C. "Your joints are still inflamed, and physical therapy can be harmful." Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment? A. The client's dietary patterns have changed since admission. B. The client has more difficulty urinating in a supine position. C. Lack of weight-bearing activity promotes bone demineralization. D. Fracture healing requires more calcium, which increases total calcium metabolism.

C. Lack of weight-bearing activity promotes bone demineralization. All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position because of an inability to assume the preferred anatomic position and the emotional effects of using a urinal, it usually does not predispose the client to developing renal calculi. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.

Pt presents with a wound which is red, tender, there is loss of the dermis, and has a some clear fluid oozing from the site. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Minor skin and tissue injury C. Partial thickness injury D. Full thickness injury

C. Partial thickness injury Partial thickness injury-->disruption at the epidermal and dermis layer

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? A.Determine if this is an allergic reaction. B. Elevate the client's head and keep the extremities warm. C. Place the client in the supine position and take the vital signs. D. Tell the client that this is not a typical sensation after receiving morphine sulfate.

C. Place the client in the supine position and take the vital signs. Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.

The older adult client who is bedridden has a documented history of protein deficiency. What will the nurse plan to monitor for? A. Anemia B. Decreased wound healing C. Pressure ulcer development D. Weight gain

C. Pressure ulcer development Rationale A. Anemia has no correlation with this client's protein deficiency. B. The client does not have an indicated wound. C. This client is at risk for pressure ulcer if he or she remains bedridden. D. Weight gain has no correlation with this client's protein deficiency.

Number one way to prevent spread of infection A. wearing gloves B. double glove C. hand washing D. wearing all PPE

C. hand washing

Elderly patients are at risk for impaired mobility due to all the following EXCEPT: A. kyphosis B. decreased bone density C. increased elasticity of ligaments D. reduced muscle tone

C. increased elasticity of ligaments A thinning of vertebral disks, shortening of the spinal column, and onset of kyphosis with spinal column compression occur. Bone density decreases and becomes brittle (particularly in females), leaving older adults more susceptible to fracture. Cartilage becomes rigid and fragile, and there is a loss of resilience and elasticity of ligaments. Muscle mass and tone reduce significantly in late adult years. Cumulatively, these changes result in mobility impairment attributable to reduced range of motion and pain in joints, reduced muscle strength, and increased risk for bone fracture.

MRSA, C. diff ,.V.R.E , and TB are all examples of ? A. Fungal infections B. Pandemics C.Health care and community acquired infections D. Parasitic infections

C.Health care and community acquired infections

A patient is contact isolation for a bacterial infection. The nurse is going to implement which of the following interventions for this patient? A. Prevent visitors from entering the room. B. Use the personal protective equipment only when knowingly coming into contact with pathogens C. Help to ensure adequate social interaction and support D. Communicate with the patient over the call light whenever possible

C: Frequently, patients in contact isolation do experience a decrease in social interaction because of the isolation. The nurse must help provide adequate social stimulation for the patient. Frequently, this is done by educating the family and friends regarding isolation practices. Isolation does not mean that the patient cannot have visitors. Visitors must be educated on how to maintain the contact isolation while with the patient, especially hygiene guidelines. Personal protective equipment must be used when entering the room of a patient in contact isolation. Nurses and visitors do not always know when they will come into contact with a pathogen, especially if it is highly virulent. The patient in contact isolation should have regular face-to-face contact with the nurse. The nurse should not use the call light system to communicate with a patient in isolation any more than any other patient.

The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient to determine which significant finding? Determines specific causes of inflammation. Identifies the location of inflammation within the body. Confirms the nonspecific presence of inflammation. Indicates a diagnosis of systemic lupus.

Confirms the nonspecific presence of inflammation.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? A. Control of pain B. Immobilization of joints C. Motivation and teaching D. Bladder training and control

Control of pain After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

An elderly bed bound patient who as been neglected presents with a stage 3 pressure ulcer to her buttocks. The nurse is able to see subcutaneous tissue. This wound would fall under which scope of skin integrity A. Intact skin and tissue B. Major skin and tissue injury C. Partial thickness injury D. Full thickness injury

D. Full thickness injury Full thickness injury--> all the way down to the subcutaneous, muscle and bone (*stage 2 ulcer would be considered partial thickness)

Populations at greatest risk for immobility A. infants B. low income C. menopausal women D. older adults

D. Older Adult Age 50 and under recommended 1,000mg calcium daily Age 50 + 1,200mg calcium daily along with vitamin D

the client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Perform a total skin self-examination monthly. D. Perform a total skin self-examination monthly with a partner.

D. Perform a total skin self-examination monthly with a partner. Rationale A. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. B. Avoiding sun exposure is a primary prevention. C. A person is physically unable to assess all the skin surfaces of his or her body. D. Performing a monthly total skin self-examination with another person is the best secondary preventive measure.

An African American mother complains of blue-gray or brown spots on the buttocks of her 3 month old baby. What does the nurse suspect? A. Mother is not changing the baby frequently enough B. The baby is having an allergic reaction to the baby powder C. That she will need to call the provider right away D. This is most likely normal and should fade within a year.

D. This is most likely normal and should fade within a year. Normal findings: Mongolian spots → blue-gray or brown spots. They can emerge on the skin of the buttocks or back, mainly in dark-skinned babies. They should fade within a year -acrocyanosis→ Deep red or purple skin and bluish hands and feet. The skin darkens before the infant takes their first breath (when they make that first vigorous cry)....should resolve in 1-2 minutes vernix → A thick, waxy substance covering the skin. This substance protects the fetus's skin from the amniotic fluid in the womb. Vernix should wash off during the baby's first bath. lanugo → Fine, soft hair that may cover the scalp, forehead, cheeks, shoulders, and back. This is more common when an infant is born before the due date. The hair should disappear within the first few weeks of the baby's life.

All of the following are normal skin findings except: A. Skin pink, warm, dry & intact B. elastic turgor C.No lesions noted D. Mucus membranes moist, intact & pink. E. nail bed with 180 degree angle F. Bony prominences free of redness

E. nail bed with 180 degree angle (this is a sign of clubbing--> should be 160 or less)

A client with considerable pain asks a nurse, "What is your opinion regarding acupuncture as a drug-free method for alleviating pain?" The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of what perspective? Ethnocentrism Prejudice Discrimination Cultural insensitivity

Ethnocentrism Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments.

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with systolic heart failure and an ejection fraction of 30%. Which other finding is most common with this diagnosis? A. Nail clubbing B. Fatigue C. Chest pain D. Peripheral edema

Fatigue Systolic heart failure is the result of a pumping problem, which is why the ejection fraction is reduced (normal is 60%). Heart failure can be caused by a heart attack, but chest pain is not normally a finding in heart failure. Nail clubbing is usually associated with disorders of the lungs. Exertional dyspnea and fatigue are common in clients with left-sided (systolic) heart failure due to fluid backing up into the lungs and pulmonary congestion. Peripheral edema is more commonly seen with right-sided (diastolic) heart failure.

The production of which immune cells are increased following exposure to viral antigens? Basophils Eosinophils Lymphocytes Neutrophils

Lymphocytes Lymphocytes are most prominent in inflammatory responses to viral antigens. Basophils are elevated during chronic inflammation/infections, eosinophils during parasitic infections and allergic reactions, and neutrophils during bacterial infections

The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown? Change the stoma pouch daily Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free Apply antiseptic cream to reddened stoma

Make sure the skin around the stoma is wrinkle-free The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.

Why is inflammation often confused with infection? Prostaglandin hormone mediates both. Purulent drainage is frequently present. Many pathophysiologic processes are shared. They produce comparable immune dysfunction.

Many pathophysiologic processes are shared. Inflammation and infection are commonly confused because many of the pathophysiologic processes associated with one are also found with the other; they overlap. Option A is incorrect because prostaglandin is a proinflammatory hormone that mediates late stages of acute inflammation. Infections are not mediated by such hormones. They are only involved in infections because inflammation occurs when infection occurs. Option B is incorrect because purulent drainage is a sign of infection, but does not occur from inflammation. Option D is incorrect because infection can overwhelm and damage the immune system very quickly (septic shock). Acute inflammation is a protective response. Chronic inflammation, over time, does damage tissue and can be detrimental to the immune system. However, these processes are not comparable.

A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki disease and treatment involving immunoglobulins. The nurse should recognize which scheduled immunizations will be delayed? Inactivated polio vaccine (IPV) Mumps, measles, rubella (MMR) Haemophilus Influenzae Type b (Hib) Diptheria, tetanus, pertussis (DTaP)

Mumps, measles, rubella (MMR) Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body's ability to form antibodies.

The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Readjust the traction for comfort Administer the ordered PRN medication Notify the health care provider Reassess the extremity in 15 minutes

Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.

A nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which activity would be an appropriate diversional activity? Play hand-held games Kick balloons with right leg Play "Simon Says" Throw bean bags

Play hand-held games Immobilization with traction must be maintained until bone ends are in satisfactory alignment and with adequate regrowth of the bone. Activities that increase mobility interfere with the goals of treatment.

Which processes are essential for development of an infection? (Select all that apply) Portal of entry Host Reservoir Microbe Portal of exit Transmission mode

Portal of entry Reservoir Portal of exit Transmission mode The host must be susceptible to infection . Not all microbes cause infection; some are beneficial. Pathogens are microbes that cause infection. All others (portal of entry, reservoir, portal of exit and mode of transmission) are essential processes.

What is the primary purpose of the inflammatory response? Promote healing Facilitate defense Support hemostasis Prevent injury

Promote healing Inflammation is a protective response that minimizes or removes pathologic agents or stimuli that triggered the inflammation, to promote healing.

Which finding differentiates infection from inflammation? Redness Purulence Swelling Tenderness

Purulence Redness, swelling (edema), and tenderness (pain) are signs of both inflammation and infection. The differentiating characteristic/finding is purulence. Purulence is a sign of infection from invasion of pathogenic microorganisms

The RN is responsible for a client in isolation. Which task can be delegated to a practical nurse (PN)? Observation of the client's total environment for risks of harm Assessment of the client's attitude about infection control Reinforcement of isolation precautions with visitors Evaluation of staff compliance with infection control measures

Reinforcement of isolation precautions with visitors PNs and UAPs can reinforce information that was originally given by the RN. The other options are responsibilites of the RN and cannot be delegated.

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? The risk of septicemia and its potential complications from treatment The risk of psychosocial adjustments and resuming previous roles The risk of oral mucous membrane injury and its associated risks The risk of insufficient community resources and emotional support

The risk of septicemia and its potential complications from treatment Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? A. Asking the client's parent B. Using Wong's "Pain Faces" C. Observing the client's body language D. Explaining the use of a 0 to 10 pain scale

Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

*Which property of pathogens makes them capable of producing disease once they invade the body? Pathogenesis Transmissibility Susceptibility Virulence

Virulence refers to the ability of pathogens to produce disease once introduced into the body. Highly virulent pathogens produce disease when small numbers invade the body; weakly virulent pathogens produce disease only when large numbers invade the body.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? a. Incontinence and inability to move independently b. Periodic diaphoresis and occasional sliding down in bed c. Reaction to just painful stimuli and receiving tube feedings d. Adequate nutritional intake and spending extensive time in a wheelchair

a. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

A 24-year-old is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action? a. To prevent transmission of infectious microorganisms b. To control the environment of the patient c. To protect the patient from infectious microorganisms d. To protect only the family

a. To prevent transmission of infectious microorganisms

A bedridden patient who is blind is admitted to a healthcare facility from his or her home with pressure ulcers on the sacral area. Which nursing diagnosis would be a priority? a. Risk for Imbalanced Body Temperature related to stage 2 pressure ulcer b. Impaired Skin Integrity related to immobility c. Feeding Self-Care Deficit related to blindness d. Activity Intolerance related to prolonged bed rest

b. Impaired Skin Integrity related to immobility The priority nursing diagnosis for this patient at this moment is Impaired Skin Integrity related to immobility. An end result of the immobility is the development of a pressure ulcer. The other nursing diagnoses may be appropriate but are not the priority on admission to the healthcare facility.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a.Use sterile gloves when removing old dressings. b.Wear gowns, caps, masks, and gloves during all care of the patient. c.Administer IV antibiotics to prevent bacterial colonization of wounds. d.Turn the room temperature up to at least 70° F (20° C) during dressing changes.

b. wear gowns, caps, masks, and gloves during all care of the patient

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations? a. Neck hyperextension should be encouraged, particularly in older people. b. Exercises should be continued until the patient is fatigued. c. Exercises should be done frequently to lessen pain for the patient d. Each joint is exercised to the point of resistance but not pain.

d. Each joint is exercised to the point of resistance but not pain.

A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by vasodilation. extravasation. neutrophils exudate.

vasodilation.