Sensory Perception, Cognition, Pt Education, and Collaboration AQ

Which criterion is used to diagnose delirium? Select all that apply. One, some, or all responses may be correct 1. No loss of recent memory 2. Disorientation to time, place, or person 3. Impaired ability to name objects 4. No perceptual disturbances 5. Acute onset, not caused by preexisting dementia

Disorientation to time, place, or person Impaired ability to name objects Acute onset, not caused by preexisting dementia

Which option is an example of a nurse managing indirect care activities? 1. Infection control 2. Patient counseling 3. Medication administration 4. Lifesaving measures

Infection control

Which term describes snide remarks or put-downs between colleagues? 1. Lateral violence 2. Metacommunication 3. Therapeutic confrontation 4. Nonverbal communication

Lateral violence

Older adults may experience a change in color perception. Which color perception usually declines as one ages? Select all that apply. One, some, or all responses may be correct. 1. Red 2. Blue 3. Violet 4. Green 5. Orange

Blue Violet Green

While performing spirometry for a patient who has emphysema, which instruction would the nurse give to help prevent hyperventilation and fatigue? 1. Breath normally for a short period between each set of 10 breaths on the incentive spirometer. 2. Breath normally for a long period between each set of 10 breaths on the incentive spirometer. 3. Breath normally for a short period between each set of 20 breaths on the incentive spirometer. 4. Breath normally for a long period between each set of 20 breaths on the incentive spirometer.

Breath normally for a short period between each set of 10 breaths on the incentive spirometer.

A patient who is 6 weeks pregnant has a family history of cystic fibrosis (CF). The patient asks the nurse if the baby will have the disease. Which information will the nurse include in the teaching of the patient? 1. Discuss carrier testing. 2. Discuss chorionic villus sampling. 3. Provide information about an amniocentesis. 4. Inform the patient that the neonate will be tested after birth

Discuss carrier testing

Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct. 1. They provide instructions from the unit manager about care in emergencies. 2. They are preprinted documents that contain orders for various clinical problems. 3. They provide legal protection to the nurse when caring for the patient. 4. They are signed by the licensed prescribing health care provider in charge at the time of implementation. 5. They are signed by the patient or the patient's relative before the treatment is started.

They are preprinted documents that contain orders for various clinical problems. They provide legal protection to the nurse when caring for the patient. They are signed by the licensed prescribing health care provider in charge at the time of implementation.

Which task can be delegated to assistive personnel (AP) regarding the maintenance of an intravenous system? 1. Changing intravenous fluid 2. Applying transparent dressings 3. Changing intravenous fluid container 4. Reporting leakage at the intravenous site

Reporting leakage at the intravenous site

While caring for a patient who has pressure injuries, the nurse finds that the skin surrounding the injury has become macerated. Which nursing intervention would be most appropriate to manage the patient's condition? Select all that apply. One, some, or all responses may be correct. 1. Obtaining necessary wound cultures 2. Reporting to the health care provider 3. Applying liquid skin barrier on the periwound skin 4. Changing the analgesic used for curing the wound 5. Reducing the exposure of wound to topical agents

Reporting to the health care provider Applying liquid skin barrier on the periwound skin Reducing the exposure of wound to topical agents

The registered nurse is teaching a nursing student about pain management in older adults with Alzheimer's disease. Which statement regarding nonpharmacological therapies indicates a need for further learning? 1. "Cognitive behavioral strategies would be appropriate." 2. "Physical pain-relieving strategies should be employed." 3. "Slow back massage and a 20-minute hand massage would be beneficial." 4. "The nonpharmacological techniques chosen should be tailored to the individual."

"Cognitive behavioral strategies would be appropriate."

The nurse provides education about tobacco use for a group of community members. Which statement made by a member of the group indicates the need for further teaching? 1. "Secondhand smoke can cause lung cancer." 2. "Sixteen different types of cancer have been linked to tobacco use." 3. "The use of electronic cigarettes is on the rise in both middle and high school teens." 4. "Electronic cigarettes are safer than regular cigarettes because they do not contain nicotine."

"Electronic cigarettes are safer than regular cigarettes because they do not contain nicotine."

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which statement by the patient would indicate that additional teaching is needed? 1. "I am at risk of injury from temperature extremes." 2. "I may be able to dress more easily with zippers or pullover sweaters." 3. "A home care referral may help me achieve a maximum degree of independence." 4. "I have right-sided partial paralysis, so I should dress the left side of my body first."

"I have right-sided partial paralysis, so I should dress the left side of my body first."

Which statement by the nursing student indicates a need for further learning regarding delegation of care to the assistive personnel (AP) for a patient who has a chest tube? 1. "I will ask the AP to properly position the patient." 2. "I will ask the AP to monitor vital signs in the patient." 3. "I will instruct the AP how to ambulate safely and transfer the patient." 4. "I will instruct the AP to report if any excessive bubbling in the water-seal chamber is observed."

"I will ask the AP to monitor vital signs in the patient."

The nurse is instructing the caregiver about home care considerations for a patient who has elastic bandages on the ankles and feet. Which statement by the caregiver indicates a need for further learning? Select all that apply. One, some, or all responses may be correct. 1. "Two sets of bandages should be available." 2. "The bandages should be applied as tightly as possible." 3. "Any changes in skin integrity should be reported to the health care team." 4. "The bandages for reducing swelling should be applied before bedtime." 5. "The bandages should be removed on alternate days for assessment of the skin."

"The bandages should be applied as tightly as possible "The bandages for reducing swelling should be applied before bedtime." "The bandages should be removed on alternate days for assessment of the skin."

Which statement or action by the nurse is characteristic of an effective hand-off report? 1. "This patient is anxious about pain after surgery; you will need to review the information about how to use a patient-controlled analgesia (PCA) pump this evening." 2. "The patient had an argument with a former boyfriend. It was like a zoo with all the yelling and name-calling." 3. The nurse talks about the problem the patient care technicians created by not assisting the patient to ambulate. 4. The nurse only talks to the oncoming nurse about the discussion of nursing care and patient goals during walking rounds.

"This patient is anxious about pain after surgery; you will need to review the information about how to use a patient-controlled analgesia (PCA) pump this evening."

The nurse is assessing a hospitalized patient with acute pain. Which question would the nurse ask the patient for an appropriate assessment? Select all that apply. One, some, or all responses may be correct. 1. "How bad is your pain now?" 2. "What makes your pain worse?" 3. "Can you describe your pain?" 4. "What is the worst pain you have had in the past 24 hours?" 5. "Show me where you hurt. Does it stay there or does it spread?"

"What makes your pain worse?" "Can you describe your pain?" "Show me where you hurt. Does it stay there or does it spread?"

The nurse discusses the World Health Organization's recommendations to prevent chronic noncommunicable illnesses with a group of adult community members. Which exercise routine does the nurse suggest? 1. 150 minutes of moderate-intensity activity per week 2. 60 minutes of vigorous aerobic activity per week 3. Strengthening exercises 4 or more days per week 4. For older adults with limited mobility, activity to enhance balance 2 or more days per week

150 minutes of moderate-intensity activity per week

Which amount of fluids per kilogram per day would the nurse encourage the patient to drink for proper wound healing? 1. 15 to 20 mL 2. 20 to 25 mL 3. 25 to 30 mL 4. 30 to 35 mL

30 to 35 mL

While assessing a patient with the Braden Scale, the nurse suspects that the patient is at a very high risk of pressure injury development. Which score might the patient have? 1. 8 2. 10 3. 13 4. 17

8

Which information can be obtained from the Mini-Mental State Examination (MMSE)? Select all that apply. One, some, or all responses may be correct. 1. Risk of epilepsy 2. Abstract thinking measurement 3. Risk of drug abuse 4. Orientation status of the patient 5. Changes in problem-solving ability

Abstract thinking measurement Orientation status of the patient Changes in problem-solving ability

The nurse is teaching a patient the use of patient-controlled analgesia (PCA). Which intervention would the nurse perform? Select all that apply. One, some, or all responses may be correct. 1. Ask the patient to describe the purpose of the PCA device. 2. Emphasize that the patient controls medication delivery. 3. Explain that the pump prevents the risk of overdose. 4. Tell family members to operate the PCA device for the patient. 5. Teach the use of PCA after the patient awakens from sedation

Ask the patient to describe the purpose of the PCA device. Emphasize that the patient controls medication delivery. Explain that the pump prevents the risk of overdose.

Which action by the new nurse would cause the charge nurse to intervene when caring for family members of a patient who died? 1. Acknowledges the loss openly 2. Reinforces the reality of the event 3. Avoids reminiscing about the patient with the family 4. Reassures the family that difficulty in sleeping is normal behavior

Avoids reminiscing about the patient with the family

The nurse determines that which type of bath is most appropriate for a patient with dementia who becomes agitated and aggressive during bathing? 1. Tub bath 2. Bag wipes 3. Therapeutic bath 4. Complete bed bath

Bag wipes

Which clinical feature is associated with delirium? 1. Lasts for months to years 2. Minimal impairment of attention 3. Onset is slow and often unrecognized 4. Calls out repeatedly with the same phrase

Calls out repeatedly with the same phrase

While assessing a patient, the nurse realizes that the patient has a progressive hearing disorder. The nurse advises the patient to obtain an assistive hearing device. Which other advice can the nurse give the patient's family to cope with the patient's hearing impairment? Select all that apply. One, some, or all responses may be correct. 1. Install smoke detectors. 2. Change doorbell to a lower-pitched sound. 3. When calling the patient, let the phone ring for a longer time. 4. Do not leave the patient alone. 5. Install lamps that turn on in response to sounds such as the doorbell, the telephone, or alarms.

Change doorbell to a lower-pitched sound. When calling the patient, let the phone ring for a longer time Install lamps that turn on in response to sounds such as the doorbell, the telephone, or alarms.

During a neurological assessment of an older-adult patient, a nurse reviews the patient's history for incidents of drug toxicity, infections, metabolic disturbances, heart failure, and/or anemia. Which manifestation might the nurse have observed in the patient that leads to this assessment? 1. Ataxia 2. Tremors 3. Delirium 4. Seizures

Delirium

How is proper documentation of a patient's health information most useful to medical insurance companies? 1. Provides preventive care to the patients 2. Determines the diagnosis-related group (DRG) of the patient 3. Reduces the cost of the monthly premium paid by the patient 4. Decreases the cost of health care services provided to the patient

Determines the diagnosis-related group (DRG) of the patient

Which strategy proposed by the nurse administrator is appropriate to improve patient-centered care? Select all that apply. One, some, or all responses may be correct. 1. Encourage the patient to participate in the decision-making process. 2. Provide information to facilitate autonomy. 3. Decrease the patient's fears and concerns about the health care provided. 4. Always involve the family members in the patient's care. 5.Simply "individualize" patient care.

Encourage the patient to participate in the decision-making process. Provide information to facilitate autonomy. Decrease the patient's fears and concerns about the health care provided.

Which nursing action would be a teaching strategy for patients and families who will be working with a pressure-redistribution surface? Select all that apply. One, some, or all responses may be correct 1. Explaining the reasons for the prescription 2. Teaching common errors associated with the prescription 3. Noting the minimum layers of linen to be used with the prescription 4. Asking the patients and caregivers to discuss possible sensations associated with the prescription 5. Requesting a return demonstration of turning and repositioning techniques with the prescription

Explaining the reasons for the prescription Teaching common errors associated with the prescription Noting the minimum layers of linen to be used with the prescription

A patient found unresponsive now opens his or her eyes when spoken to, gives correct answers to simple questions when asked, and usually sleeps when left unattended. Which category of the Glasgow Coma Scale has the nurse assessed? 1. Eye opening and motor activity 2. Motor activity and motor response 3. Eye opening and best verbal response 4. Best verbal response and best motor response

Eye opening and best verbal response

The nurse teaches a patient about cranial nerves to help explain why the right side of the patient's mouth droops instead of moving up into a smile. Which nerve does the nurse explain to the patient? 1. Facial (VII) 2. Trigeminal (V) 3. Hypoglossal (XII) 4. Spinal accessory (XI)

Facial (VII)

Which outcome is expected after effective documentation? Select all that apply. One, some, or all responses may be correct. 1. Reduction of the level of care required 2. Facilitation of proper insurance reimbursement 3. Efficient use of time 4. Enhanced continuity of care 5. Protection for the nurse from legal recourse

Facilitation of proper insurance reimbursement Efficient use of time Enhanced continuity of care Protection for the nurse from legal recourse

The nurse educator provides teaching to a group of nurses about cultural aspects of hygiene practice and would include which implication for patient-centered care? Select all that apply. One, some, or all responses may be correct. 1. Family members are allowed to participate in care. 2. Gender-congruent caregivers should be provided if requested. 3. The patient's hair can be shaved without prior discussion with the patient or the patient's family. 4. Privacy should be maintained only for women from Middle Eastern cultures. 5. Hispanic patients should not have their lower torso exposed.

Family members are allowed to participate in care. Gender-congruent caregivers should be provided if requested.

A patient has an inability to understand language or communicate orally. Which type of aphasia is the patient experiencing? 1. Global 2. Receptive 3. Expressive 4. Perception

Global

Which challenge do nurses face in the health care system? Select all that apply. One, some, or all responses may be correct. 1. Improving access to health care 2. Generating profits 3. Maintaining high-quality care 4. Reducing the cost of health care 5. Focusing on rehabilitation

Improving access to health care Maintaining high-quality care Reducing the cost of health care

Which action would the nurse perform during the planning phase of a patient with a sleep disturbance? 1. Teach the patient about sleep-hygiene measures. 2. Review factors affecting the patient's sleep. 3. Ask the patient if expectations of care are being met. 4. Involve the sleep partner in the selection of interventions

Involve the sleep partner in the selection of interventions

The nurse is planning to conduct a hearing acuity test on a patient. Which activity would the nurse use to assess this sensory function? Select all that apply. One, some, or all responses may be correct. 1. Ask the patient to read the newspaper. 2. Observe the patient's behavior in a group. 3. Use the tuning fork test. 4. Use the spoken word test. 5. Ask the patient to identify colors

Observe the patient's behavior in a group. Use the tuning fork test. Use the spoken word test.

The nurse assesses the patient's level of consciousness using a Glasgow Coma Scale (GCS). Which parameter does this test evaluate? Select all that apply. One, some, or all responses may be correct. 1. Lateralization of sound 2. Opening of eyes 3. Verbal response 4. Motor response 5. Air and bone conduction

Opening of eyes Verbal response Motor response

The nurse identifies that which patient condition may increase the risk of tissue ulceration because of excessive soaking of the feet? 1. Renal calculi 2. Cirrhosis of the liver 3. Peripheral vascular disease 4. Congestive heart failure

Peripheral vascular disease

The nurse is consulting with a patient about meal planning on an allocated budget. Which advice would the nurse provide to help ensure good nutrition on a budget? Select all that apply. One, some, or all responses may be correct. 1. Plan menus a week in advance. 2. Avoid grocery shopping when hungry. 3. Replace cheese or bean dishes with meat. 4. Use evaporated milk for cooking. 5. Choose frying food over steaming

Plan menus a week in advance. Avoid grocery shopping when hungry Use evaporated milk for cooking

The nurse is asked to assist an elderly patient with ambulation at 5:00 a.m. and finds the patient distressed and not oriented to time, place, or self. Which action by the nurse is most appropriate? 1. Postpone the ambulation to another time. 2. Assist the patient in walking as scheduled. 3. Ask for help from another colleague to ambulate the patient. 4. Remove any obstacles on the floor before the ambulation.

Postpone the ambulation to another time

Which normal visual change is associated with aging? Select all that apply. One, some, or all responses may be correct. 1. Reduced visual fields 2. Impaired night vision 3. Reduced glare sensitivity 4. Increased depth perception 5. Reduced color discrimination

Reduced visual fields Impaired night vision Reduced color discrimination

A patient is unable to conduct normal activities because of visual impairment. Which precaution could the family members take to help the patient perform normal activities? Select all that apply. One, some, or all responses may be correct. 1. Remove clutter from the floor. 2. Keep all flooring in good repair. 3. Avoid painting the edge of steps. 4. Use low-pile carpeting in the home. 5. Use light fixtures with limited illumination.

Remove clutter from the floor. Keep all flooring in good repair Use low-pile carpeting in the home

Which condition may cause functional incontinence? 1. Fecal impaction 2. Acute confusion 3. Sensory impairment 4. Excessive urine output

Sensory impairment

Which positioning of the patient would be appropriate while administering rectal suppositories? 1. Sims' position 2. Sitting position 3. Supine position 4. Dorsal recumbent position

Sims' position

Which level of prevention describes the nurse working in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered a motor vehicle accident? 1. Primary 2. Secondary 3. Tertiary 4. Quaternary

Tertiary

Which law is the nurse violating when faxing a patient's medical record to an unknown number? 1. The American Recovery and Reinvestment Act (ARRA) 2. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 3. The Health Information Technology for Economic and Clinical Health Act (HITECH) 4. The Joint Commission (TJC) Act

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Which symptom is associated with carpal tunnel syndrome? Select all that apply. One, some, or all responses may be correct. 1. Tingling 2. Weakness 3. Numbness 4. Blurred vision 5. Reduced taste sensation

Tingling Weakness Numbness

The nurse provides care for a patient who is admitted to the emergency department after a head injury. The nursing team leader observes the nurse providing care and intervenes when the nurse performs which action? 1. Turns the patient to the side 2. Applies a cervical collar to the patient 3. Notifies the health care provider immediately of the patient's arrival 4. Assesses the patient in the absence of the health care provider

Turns the patient to the side

The nurse provides discharge teaching for a patient and implements which strategy to ensure that the patient understands the information? 1. Provides large printed material 2. Uses teach-back 3. Reads the information to the patient aloud slowly 4. Includes the patient's caregivers in the education

Uses teach-back