Unit 3 LSoN

Principles of Wound Healing

- Intact skin is the first line of defense against microorganisms; a break in the integrity of skin increases risk of infection; Careful hand hygiene is probably the single most effective method for preventing wound infections -The body responds systemically to trauma; example- a surgical incision can cause a variety of systemic reactions, increased temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension and hormonal changes - An adequate blood supply is essential for the body's normal response to any injury; blood transports leukocytes, erythrocytes, and platelets to injury site; Antibodies are carried in plasma; increased circulation removes toxins and debris and provides nutrients and oxygen. Areas of the body with good blood supply, heal faster - Normal healing is promoted when the wound is free of foreign material, such as exudate, dead or damaged tissue cells, pathogenic organisms, or embedded fragments of bone, metal, glass or other substances; in some situations a collection of pus or foreign body is walled off and healing occurs around it to from an abscess. - The ability to handle altered skin integrity depends on the extent of the damage and the person's general state of health; the capacity to deal adequately with a wound is limited when a healthy person sustains massive injury, when patient has a chronic illness or depressed immune system, or when patient is very young or very old - The body's response to a wound is more effective with proper nutrition. Undernourished patients are at greater risk because they have difficulty mounting their cell mediated defense system. Certain quantities of glucose are necessary to meet energy requirements for wound healing. Various vitamins and minerals are necessary for wound healing; vitamin A for collagen synthesis and epithelialization, Vitamin B is a cofactor of enzyme reactions needed for healing, Vitamin C is needed for collagen syntheses, capillary formation, and resistance to infection; vitamin K is needed for synthesis of thrombin; Zinc, copper, iron assist in collagen synthesis; Manganese serves as an enzyme activator

General Skin Care Principles

-Assess the patients skin daily - Cleanse the skin when indicated, such as when soiled using a no rinse ph balanced cleanser - Avoid using soap and hot water -Avoid excessive friction and scrubbing - Minimize skin exposure to moisture (incontinence, wound leakage) use a skin barrier product that is necessary - Use emollients (moisturizer)

To pack a wound

-Check the wound care order or nursing care plan -Perform hand hygiene -Use standard precautions; use appropriate transmission based precautions when indicated - Check the patient's identification -Explain what you are going to do to the patient -Provide privacy by closing the door to the room and pulling the bedside curtain -Cleanse the wound and periwound skin as prescribed -Apply a skin barrier, such as skin prep, to the areas of skin where the dressing or adhesive tape will be placed and to areas around the wound where drainage may come in contact with the skin - Moisten packing material as necessary and as indicated by the manufacturer's directions or medical orders -Loosely pack the wound cavity just until the wound surfaces and edges are covered. If tunneling is present, pack the tunneling area first, then the base of the wound. Alternately, follow the manufacturer's directions for application - Ensure that all wound surfaces are covered and kept moist -Do not allow packing to overlap the wound edges; maceration of surrounding tissues could occur -Cover with appropriate top dressing

applying a new dressing

-Check the wound care order or nursing care plan -Perform hand hygiene -Use standard precautions; use appropriate transmission based precautions when indicated -Check the patient's identification -Explain what you are going to do to the patient -Provide privacy by closing the door to the room and pulling the bedside curtain -Put on gloves -Cleanse the wound and periwound skin, as prescribed. -Apply a skin barrier, such as Skin Prep, to the areas of skin where the dressing adhesive or tape will be placed and to areas around the wound where drainage may come in contact with skin -Gently place the dressing at the wound center and extend it at lease 1 inch beyond the wound in each direction. Alternately, follow the manufacturer's directions for application -Remove gloves when the dressing is in place, before handling tape, if used -Do not apply tape under tension to prevent blisters and skin shearing -Perform hand hygiene

Meeting the Oral Hygiene Needs of Patients with Cognitive Impairments

-Choose a time of day when the patient is most calm and accepting of care -Enlist the aid of a family member or significant other -Break the task into small steps -Provide distraction, such as playing favorite music while providing care - Allow the patient to participate . The nurse can put a hand over the patient to guide the acitivity -Start the activity, showing the patient what to do, then let the patient take over -Withdraw and try again later if the patient strongly refuses care -Document effective and ineffective interventions to provide appropriate information for staff to give consistent, effective care

Guidelines for Nursing care Applying bandages and binderg

-Clean the area to be covered and dry it thoroughly before applying a bandage or binder, because prolonged heat and moisture on the skin may cause skin breakdown -Bandage the body part in the normal functioning position to prevent deformities and discomfort -Apply the bandage or binder with sufficient pressure to provide the amount of immobilization or support desired, to remain in place, and to secure a dressing when present. Do not apply pressure to such a degree that circulation to the involved body part is impeded -Maintain equal tension with all bandage turns; avoid unnecessary and uneven overlapping of turns -After application, assess circulation and comfort at regular intervals

Skin care problems: Dry skin- the skin loses moisture and may crack and peel, or become irritated and inflamed. Symptoms include scaling, flaking, itching, and cracks in the skin

-Keep baths or showers short, and/or bathe less frequently. - use warm, not hot water to bathe - use as little as possible. Try mild cleansers or soaps -dry skin thoroughly and gently. -use moisturizers at least daily -drink plenty of water throughout the day -use a humidifier if the air is dry

Shaving

-Perform hand hygiene -Identify patient. Explain procedure to patient -Cover the patient's chest with a towel or waterproof pad. Fill a bath basin with comfortably warm water - Press a warm washcloth on the patient's skin to soften the hair - Dispense shaving cream into palm of hand. Rub hands together, then apply to the area to be shaved in a layer approximately 0.5 inch thick. -With one hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin shaving. If shaving the face, shave with the direction of hair growth in downward, short strokes. If shaving a leg, shave against the hair in upward short strokes. -Remove residual shaving cream with a wet washcloth - If patient requests, apply aftershave or lotion to area shaved - Remove and discard gloves and perform hand hygiene

Meeting the needs of patient's with dementia

-Shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient. Focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness -Individualize patient care. Consult the patient, the patient's record, family members, and other caregivers to determine patient preferences. -Consider what can be learned from the behaviors associated with dementia about the needs and preferences of the patient. A patient's behavior may be an expression of unmet needs; unwillingness to participate may be a response to uncomfortable water temperatures or levels of sound or light in the room. -Ensure privacy and warmth -Consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options -Maintain a relaxed demeanor. Use calming language. Use one step commands. Try to determine phrases and terms the patient understands in relation to bathing and make use of them. Offer frequent reassurance -Encourage independence. Use hand over hand or a guided technique to cue the patient regarding the purpose of the interaction and allow the patient to perform some of the activities independently - Explore the need for routine analgesia before bathing. Move limbs carefully and be aware of signs of discomfort during bathing -Wash the face and hair at the end of the bath or at separate time. Water dripping in the face and having a wet head are most often the most upsetting parts of the bathing process for people with dementia

Skin Care Problems Acne A skin condition that is characterized by clogged pores (blackheads, whiteheads, pimples) caused by dead skin cells, and sebum (oil) sticking together in the pore. Sometimes bacteria that live on the skin also get inside the clogged pore. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large amount of bacteria inside, the pore becomes inflamed (red and swollen). If the inflammation goes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms and buttocks

-avoid squeezing or picking infected areas because this can spread the infection and cause scarring -gently wash the face twice a day with a mild cleanser and warm (not hot) water -use oil free, water based moisturizers and make up. Look for products that are "noncomedogenic" or "nonacnegenic". Use cosmetics soaringly to avoid further blockage of sebaceous ducts -keep hair

Spasticity

A condition of increased muscular tone causing stiff and awkward movements

Concept Mastery Alert- Skin integrity and wound care

A helpful way to remember which technique to use for wound care is this: Surgery occurs under sterile conditions, so surgical wounds= sterile technique; pressure ulcers= clean technique

A nurse performing an assessment of a newborn in the neonatal unit records these findings: heart rate 85bpm, irregular respiratory rate, normal muscle tone, weak crying and bluish tint to skin. Using the APGAR scoring chart, what would be the score for this newborn? A.5 B.7 C.8 D.10

A. 5 A newborn with a heart rate less than 100bpm, irregular respiratory effort, normal muscle tone, weak cry, and bluish tint to the skin scores a 5 on the APGAR char

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces? A. A patient sitting in a chair who slides down B. A patient who lifts himself up on his elbows C. A patient who lies on wrinkled sheets D. A patient who must remain on his back for long periods of time

A. A patient sitting in chair who slides down

The nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device? A. A patient who has leg strength and can cooperate with the movement B. A patient who has an abdominal incision C. A patient with a thoracic incision D. A patient who is confined to bedrest

A. A patient who has leg strength and can cooperate with the movement

The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention A. A surgical incision with sutured approximated edges B. A large wound with considerable tissue loss allowed to heal naturally C. A wound left open for several days to allow edema to subside D. A wound healing naturally that becomes infected

A. A surgical incision with sutured approximated edges

The nurse moves a patient's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A. Adduction B. Abduction C. Circumduction D. Extension

A. Adduction

A nurse is caring for an 80 year old female patient who is living in a long term care facility. To help this patient adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? A. Tell me about how you celebrated Christmas when you were young B. Tell me how you plan to spend your time this weekend C. Did you enjoy the choral group that performed here yesterday D. Why don't you want to talk about your feelings

A. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences

The nurse is assessing the wounds of patients. Which patients would the nurse place at risk for delayed wound healing? Select all that apply. A. An older adult who is bedridden B. A patient with a peripheral vascular disorder C. A patient who is obese D. A patient who eats a diet high in vitamins A and C E. A patient who is taking corticosteroid drugs F. A 10 year old patient with a surgical incision

A. B. C.F. An older adult who is bedridden; a patient with peripheral vascular disorder; a person who is obese; a patient who is taking corticosteroid drugs

When performing a pain assessment on patient, the nurse observes that the patient guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response? A. Behavioral B. Physiologic C. Affective D.Psychosomatic

A. Behavioral

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply) A. Metabolism B. Ability to hear low pitched sounds C. Gastric secretions D. Far vision E. Glomerular filtration

A. C.E. Metabolism, Gastric secretions, Glomerular filtration

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hours B. Instruct the client to cough and deep breathe every 4 hours C. Restrict the clients fluid intake D. Reposition the client every 4 hours

A. Encourage the client to perform antiembolic exercises every 2 hours. Encourage the client to perform antiembolic exercises every 1 to 2 hours to promote venous return and reduce the risk of thrombus formation

A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure? A. Enlist the assistance of two or three other nurses to perform the procedure. B. Use a friction reducing sheet that extends from below shoulder to above hips C. Have the patient cross his or her arms on the chest and place a pillow over them. D. Have two nurses stand on the side of the bed in the direction the patient will be turned

A. Enlist the assistance of 2 or 3 other nurses to perform the procedure

A nurse is beginning a complete bed bath for a client. After removing the clients gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face. The greatest risk to a client during bathing is the transmission of pathogens from one area of the body to another. Begin with the cleanest area of the body and proceed to the least clean area. The face is generally the cleanest area, and washing it first follows a systematic head to toe approach to client care

A 2-year-old grabs a handful of cake from the table and stuffs it in his mouth. According to Freud, what part of the mind is the child satisfying? A. Id B. Superego C. Ego D. Unconscious mind

A. Freud defined the id as the part of the mind concerned with self-gratification by the easiest and quickest available means.

The nurse is assessing a patient for the chronology of the pain she is experiencing. Which is an example of an appropriate interview question to obtain this data? A. How does the pain develop and progress B. How would you describe your pain C. How would you rate the pain on a scale of one to ten D. What do you do to alleviate your pain and how well does it work

A. How does the pain develop and progress

A nurse encourages residents of a long term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure health aging. This intervention is based on which aging theory? A. Identity- continuity theory B. Disengagement theory C. Activity theory D. Life review theory

A. Identity-continuity theory

A nurse caring for patients in a long term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? A. Increase physical activities during the day B. Encourage short periods of napping during the day C. Increase fluids during the evening D. Dispense diuretics during the afternoon hours

A. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening

The pediatric nurse teaches parent about normal sleep patterns in their children. Which of the following teaching points should the nurse include? A. Inform parents that daytime napping decreases during the preschool period, and by the age of 5 years, most children no longer nap B. Teach parents of infants to report any eye movements, groaning, or grimacing by their infant during sleep periods C. Advise patients that waking from nightmares or night terrors is common during the adolescent stage. D. Inform parents about the preschool child's awareness of the concept of death possibly occurring and encourage patients to help alleviate the child's fears

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

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply) A. Inspect the feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over the counter products to treat abrasions E. Wear cotton socks

A. Inspect the feet daily. Clients who have diabetes mellitus are at increased risk for infection and diminished sensitivity in the feet, so they should inspect them daily B. Use moisturizing lotion on the feet. The client should use moisturizing lotions (but not between the toes) to help keep the skin smooth and supple. C. Wear cotton socks. The client should wear cotton socks each day

A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? A.Stage I NREM sleep B. Stage II NREM sleep C. Stage IV NREM sleep D. REM sleep

A. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects? A. It activates the immune system B. It increases the level of epinephrine C. It decreases heart rate D. It causes shallow breathing

A. It activates the immune system

When caring for a patient with dentures, what shoud the nurse teach the patient? A. Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit B. Dentures should be wrapped in tissue or a disposable wipe when out of the mouth and stored in a disposable cup C. Dentures should never be stored in water because the plastic material may wrap. D. A brush and nonabrasive powder should be used to clean the dentures, and hot water should be used to rinse them

A. Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit

To promote sleep in a patient, a nurse suggests what intervention A. Follow the usual bedtime routine if possible B. Drink two or three large glasses of water at bedtime C. Have a large snack at bedtime D. Take a sedative-hypnotic every night at bedtime

A. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime, instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly

Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? A. Acute Pain related to fear of taking prescribed postoperative medications B. Impaired Physical Mobility related to surgical procedure C. Anxiety related to outcome of surgery D. Risk for Infection related to surgical incision

A. Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation

A nurse is teaching new mothers about infant care and safety. What would the nurse accurately include as a teaching point? A. Keep infants younger than six months out of direct sunlight B. Use honey instead of sugar in homemade baby food C. Place the baby on his or her stomach for sleeping D. Keep crib rails down at all times

A. Nurses should teach parents to keep infants younger than six months out of direct sunlight and cover them with protective hats and clothes. The nurse should also teach parents not to add honey or sugar to homemade baby food, to place the baby on the back for sleeping to prevent SIDS, and to keep the crib rails up at all times

A mother tells the nurse that she is worried about her 4 year old daughter because she is overly attached to her father and won't listen to anything I tell her to do. What would be the nurses best response to the parental concern? A. Tell the mother that this is normal behavior for a preschooler B. Tell the mother that she and her family should see a counselor C. Tell the mother that she should try to spend more time with her daughter D. Tell the mother that her child should be tested for autism

A. Preschoolers, according to Freud, are in the phallic stage, with the biologic focus primarily genital, The child has a sexual desire for the opposite-sex parent, but as a means of defense strongly identifies with the same sex parent. This is normal behavior for a preschooler, and the family does not need counseling or autism testing. Spending more time with the child is always a good idea, but is not the solution to this concern

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse who asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggraavating and relieving factors

A. Presence of associated manifestation

A nurse working in a long term care facility uses proper patient ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift

A. Preventive measures should focus on careful assessment of the patient environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? A. Mechanical B. Thermal C. Chemical D. Electrical

A. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores and pressure from a cast are mechanical stimulants. Sunburn is a thermal stimulant. An acid burm is the result of a chemical stimulant. The jolt fro a lightening bolt is an electrical stimulant

The nurse observes a hospitalized preschooler who clings excessively to his mother and uses infantile speech patterns. This child is exhibiting what type of behavior? A. Regression B. Separation anxiety C. Negativism D. Self -expression

A. Regression

A nurse caring for elderly patients in a long term care facility encourages an older adult to reminisce about her past life events. This life review, according to Erickson, is demonstrating what developmental stage of the later adult years? A. Ego integrity B. Generativity C. Intimacy D. Initiative

A. Reminiscence during the older years of ones life provides a sense of fulfillment and purpose (ego integrity). Generativity is a developmental stage of the middle adult years. Intimacy is a developmental task of the adolescent to adult years, and initiative is a task of the preschooler to early school age years

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the clients plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client

A. Schedule rest periods during morning care. Planning for rest periods during morning care will help prevent fatigue and continue to foster independence.

A nurse is recommending aerobic exercise for a patient who is overweight Which exercise might the nurse suggest? A. Swimming B. Lifting weights C. Yoga D. Stretching exercises

A. Swimming

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? A. CRIES scale B. COMFORT scale C. FLACC scale D. FACES scale

A. The CRIES pain scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiological factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC (F-Faces; L-Legs; A-Activity; C-Cry; C- Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? A. Document the findings and continue to monitor the patient. B. Administer antipyretics, as ordered. C. Increase the frequency of assessment to every hour and notify the patient's primary care provider. D. Increase the frequency of wound care and contact the primary care provider for an antibiotic order.

A. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the sight of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? A. The nurse places the patient in a sitting position while the family visits B. The nurse places identification tags on both the shroud and the ankle C. The nurse removes soiled dressings and tubes D.The nurse makes sure a death certificate is issued and signed

A. The nurse places the patient in a sitting position while the family visits

The nurse caring for a postoperative patient is cleaning the patient's wound. Which nursing action reflects the proper procedure for wound care? A. The nurse works outward from the wound in lines parallel to it B. The nurse uses friction when cleaning the wound to loosen dead cells C. The nurse swabs the wound with povidone-iodine to fight infection in the wound. D. The nurse swabs the wound from the bottom to the top

A. The nurse works outward from the wound in lines parallel to it

A nurse is teaching parents of preschoolers about growth and development of their children. Which teaching point would the nurse include? A. The pace of growth and development is specific for each person B. Growth and development occur at similar stages and rates for each age group C. Aspects of growth and development cannot be modified D. Growth and development do not follow regular predictable trends

A. The pace of growth and development is specific for each person

A nurse on the night shift checks on a patient and suspects that the patient is in REM sleep. Which patient cue is indicative of this stage of sleep? A. The patient's eyes dart back and forth quickly B. The patient has a slow, regular pulse. C. The patient's metabolism and body temperature have decreased D. The patient's blood pressure decreases

A. The patient's eyes dart back and forth quickly

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? A. Support weight on stronger leg and cane and advance weaker foot forward. B. Hold the cane in the same hand of the leg with the most deficit C. Stand with as much weight distributed on the cane as possible D. Do not use the cane to rise from a sitting position, as this is unsafe

A. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position

A nurse is measuring the depth of at patient's puncture wound. Which technique is recommended? A. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down. B. Draw the shape of the wound and describe how deep it appears in centimeters. C. Gently insert a sterile applicator into the wound and move it in a clockwise direction D. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker

A. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible appliarot with saline and insert it gently into the wound at a 90 degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wounds margin; and remove the swab and measure the depth with a ruler

A nurse is choosing activities for a toddler who is hospitalized for tests. Which toy would be most appropriate for this patient? A. Tricycle B. Basketball C. Building blocks D. Stuffed animal

A. Tricycyle

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the clients head to the side B. Place two fingers in the clients mouth to open it C. Brush the clients teeth once per day D. Inject a mouth rinse into the center of the clients mouth

A. Turn the clients head to the side. Position the clients head on the side unless there is a contraindication for this position, to reduce risk of aspiration

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. Patient who has uncontrolled hypothyroidism B. A patient with coronary artery disease C. A patient who has gastroesophageal reflux (GERD) D. A patient who is HIV positive E. A patient who is taking corticosteroids for arthritis F. A patient with a urinary tract infection

A.B.C. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterms

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. A. It promotes the patient's sense of well-being. B. It prevents deterioration of the oral cavity. C. It contributes to decreased incidence of aspiration pneumonia. D. It eliminates the need for flossing E. It decreases oropharyngeal secretions F. It compensates for an inadequate diet.

A.B.C. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? Select all that apply A. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary B. Change the dressing midway between meals C. Apply a protective ointment, if appropriate, to cleansed skin surrounding the drain wound D. Apply another layer of protective ointment or paste on the top of the previous layer when changing dressings E. Apply an absorbent dressing material as the first layer of the dressing F. Apply a nonabsorbent material over the first layer of absorbent material

A.B.C. Administer a prescribed analgesic 39 to 45 minutes before changing the dressing if necessary. Change the dressing midway between meals C. Apply a protective ointment, if appropriate, to cleansed skin surrounding the drain wound

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serasanguineous drainage E. Decrease in thirst

A.B.C. Increase in incisional pain- expect the client to have pain and tenderness at the wound site with an incisional infection Fever and chills- Expect fever and chills Reddened wound edges- Expect the client to have reddened or inflamed wound edges with an incisional infection

A nurse is teaching a patient how to walk with crutches. Which teaching points are recommended guidelines for this activity? (Select all that apply) A. Keep elbows close to sides B. Prevent crutches from getting closer than 3 inches to the feet C. Use the four point gait for patients who may bear weight on both feet. D. Use the swing to gait for patient who may bear weight on one foot E. Use the two point gait for patients who may not bear weight on either foot F. When climbing stairs, advance the unaffected leg past the crutches, then place weight on the crutches, then advance the affected leg and then the crutches

A.B.C. Keep elbows close to sides. Prevent crutches from getting closer than 3 inches to the feet. Use the four point gait for patients who may bear weight on both feet

The nurse is teaching the practice of stimulus control to a patient who has insomnia. The nurse would include which teaching points in the teaching plan? (Select all that apply) A. Recommend that the patient use the bedroom for sex and sleep only B. Instruct the patient to leave the bedroom if he or she cannot get to sleep within 15-20 minutes; he or she should return to the bedroom when sleepy C. Instruct the patient to get up the same time every day no matter what time he or she fell asleep D. Allow the patient to nap during the day if he or she could not sleep during the night E. Instruct the patient to exercise moderately 1 hour before going to bed. F. Encourage the patient to consume one or two alcoholic drinks to help him or her relax before bedtime

A.B.C. Recommend that the patient use the bedroom for sex and sleep only. Instruct the patient to leave the bedroom if he or she cannot get to sleep within 15-20minutes; he or she should return to the bedroom when sleepy. Instruct the patient to get up the same time every day no matter what time he or she fell asleep

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. A. Serous drainage is composed of the clear portion of the blood and serous membranes B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood C. Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding D. Purulent drainage is composed of white blood cells, dead tissue, and bacteria E. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor F. Serosanguineous drainage can be dark yellow or green depending on the causative organism

A.B.C.D. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquified dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select all that apply. A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles

A.B.D. Request assistance when repositioning when a client. To reduce the risk of injury, at least two staff members should reposition clients. Avoid twisting your spine or bending at the waist. Twisting the spine or bending at the waist increases the risk for injury Use smooth movements when lifting and moving clients. Using smooth movements instead of sudden or jerky muscle movements helps prevent injury.

A nurse is making an unoccupied bed for a hospitalized patient. Which actions are appropriate steps for the nurse to perform? (Select all that apply) A. First, adjust the bed to the high position and drop the side rails B.Fold reusable linens on the bed in fourths and hang them over a clean chair C. Snugly roll the soiled linens into the bottom sheet and place on the floor next to the bed D. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed E. Tuck the bottom sheets securely under the head of the mattress, forming a corner according to agency policy F. Place the pillow at the head of the bed with the closed end facing toward the window

A.B.D.E First, adjust the bed to the high position and drop the side rails. Fold reusable linens on the bed in fourths and hang them over a clean chair. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. Tuck the bottom sheets securely under the head of the mattress, forming a corner according to agency policy

A nurse caring for a patient with hypersomnia investigates the cause of the sleep disorder. What are possible causes to consider? (Select all that apply) A. Another sleep disorder, such as sleep apnea B. Depression C. Malnourishment D. Alcohol abuse E. Some medications F. Eating disorders

A.B.D.E. Another sleep disorder, such as sleep apnea. Depression. Alcohol abuse. Some medications

A high school nurse is counseling parents of teenagers who are beginning high school. Which issues would be priority topics of discussion for this age group? Select all that apply. A. The influence of peer groups B. Bullying C. Water Safety D. Eating disorders E. Risk taking behaviors F. Immunization

A.B.D.E. Appropriate topics of discussion for parents of adolescents include peer groups, bullying, eating disorders, and risk taking behaviors. Immunizations would be appropriate for parents of children from infants to school age, and water safety should be taught in the preschool years

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? Select all that apply A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake for at least 2 hours before bedtime

A.B.D.E. Relaxation techniques, especially muscle relaxation, can help promote sleep and rest. Following an exercise routine regularly, at least 2 hours prior to bedtime, can help promote sleep and rest. For example, rather than trying to sleep with a restless pet at the foot of the bed, move the pet to another sleep area. Limiting fluids for a few hours before bedtime helps minimize getting up to urinate

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply A. Daily mental activities B. Daily physical activities C. Morning and evening body temperature D. Daily measurement of fluid intake or output E. Presence of anxiety or worries affecting sleep F. Morning and evening blood pressure readings

A.B.E. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary

A nurse is teaching parents of preschoolers about normal development for this age group. Which teaching points would the nurse include? (Select all that apply) A. By 6 years of age the preschoolers head is close to adult size B. The preschoolers body is less chubby and more coordinated C. The preschooler still has baby teeth D. The average weight of a preschooler is 60 pounds E. The preschooler is able to skip, jump, and throw a ball F. The preschooler is more egocentric than the toddler

A.B.E. By 6 years of age the preschoolers head is close to adult size. The preschooler's body is less chubby and more coordinated. The preschooler is able to skip, jump, and throw a ball

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. A. Use standard precautions or transmission-based precautions when indicated. B. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. C. Clean the wound in full or half circles beginning on the outside and working toward the center. D. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. E. Clean to at least one inch beyond the end of the new dressing if one is being applied. F. Clean to at least three inches beyond the wound if a new dressing is not being applied.

A.B.E. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) Use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied

Nurses who care for diverse populations must be aware of patterns of disease that are more likely to affect certain ethnic or racial groups. Which examples accurately reflect these profiles? (Select all that apply.) A. Black American men are 30% more likely to die from heart disease than Non Hispanic white men B. Hispanics have a higher rates of obesity than non-Hispanic Caucasians. C. American Indian/ Alaska Natives have an infant mortality rate 75% higher than that of caucasians. D. Black adults are diagnosed with diabetes and die from diabetes almost three times as often as white adults E. Black Americans have the highest mortality rate of any minority for most major cancers F. Tuberculosis is 22 times more common in Asian Americans than the white population

A.B.E.F. Black American men are 30% more likely to die from heart disease than Non Hispanic white men. Hispanics have higher rates of obesity than non-Hispanic caucasians. Black Americans have the highest mortality rat of any minority for most major cancers. Tuberculosis is 11 times more common in Asian Americans than the white population

A nurse who formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A. Arrange for assessment for depression and treatment B. Discourage napping during the day C. Decrease fluids during the evening D. Administer diuretics in the morning E. Encourage patient to engage is some type of physical activity F. Assess medication for side effects of sleep pattern disturbance

A.B.E.F. For patients who are having trouble initiating sleep, the nurse should arrange for an assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate inverntions for Disturbed Sleep Pattern: Maintaining sleep

A nurse caring for older adults in a long term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? (Select all that apply) A. Fatty tissue is redistributed B. The skin is drier and wrinkles appear C. Cardiac output increases D. Muscle mass increases E. Hormone production increases F. Visual and hearing acuity diminishes

A.B.F. Fatty tissue is redistributed. The skin is drier and wrinkles appear. Visual and hearing acuity diminishes

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? (Select all that apply) A. A patient cradles a wrist that was injured in a car accident B. A child is moaning and crying due to a stomachache C. A patient's pulse is increased following a myocardial infarction D. A patient in pain strikes out at a nurse who attempts to bathe him E. A patient who has chronic cancer pain is depressed and withdrawn F. A child pulls away from a nurse trying to give him an injection

A.B.F. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiological of involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature

A nurse is counseling adolescents in a group home setting. Which statements accurately describe the cognitive and psychosocial development of this age group? (Select all that apply) A. The concept of time and its passage enable the adolescent to set long term goals B. According to Piaget, adolescence is the stage when the cognitive development of formal operations is developed C. In the adolescent, egocentrism diminishes and is replaced by an awareness of the needs of others D. Based on Erickson's theory, the adolescent tries out different roles and personal choices and beliefs in the stage called generativity vs. stagnation E. Ther parents act as the greatest influence on the adolescent. F. According to Havighurst, more mature relationships with boys and girls are achieved by the adolescent

A.B.F. The concept of time and its passage enable the adolescent to set long term goals. According to Piaget, adolescence is the stage when the cognitive development of formal operations is developed. According to Havighurst, more mature relationships with boys and girls are achieved by the adolescent

A nurse is performing pain assessments on patient's in a physician's office. Which patients would the nurse document as having acute pain? (select all that apply) A. A patient who is having an MI B. A patient who has diabetic neuropathy C. A patient who presents with the signs and symptoms of appendicitis D. A patient who fell and broke an ankle E. A patient who has rheumatoid arthritis F. A patient who has bladder cancer

A.C.D. A patient who is having an MI. A patient who presents with the signs and symptoms of appendicitis. A patient who fell and broke his ankle

A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catchup, during young adulthood? (Select all that apply) A. Influenza B. Measles, Mumps, Rubella C. Pertussis D. Tetanus E. Polio

A.C.D. Influenza, Pertussis, Tetanus

A nurse is using Freud's theory of psychoanalytic development to assess the development of children in the phallic stage of this theory. Which developmental milestones would the nurse expect in this age group? (Select all that apply) A. The child becomes toilet trained B. The child has increased interest in gender differences C. The child is possessive of the opposite sex parent D. The child is curious about genitals and masturbation increases E. The child prepares for adult roles and relationships F. The child experiences sexual pressures and conflicts

A.C.D. The child becomes toilet trained. The child is possessive of the opposite sex parent. The child is curious about genitals and masturbation increases

A nurse working in a community clinic assists middle adult patients to follow guidelines for health related screening and immunizations. What preventative measures would the nurse recommend for this population? (Select all that apply) A. A physical exam every year from age 40 on B. Clinical skin examination every 3 years C. Breast self examination every month for women D. Pelvic examination and Pap exam at least every 3 years for women E. Prostate specific antigen (PSA) test every year for men F. Zoster vaccine, live (Zostavax) for adults 50 years and older

A.C.D.E. A physical exam every year from age 40 on. Breast self examination every month for women. Pelvic examination and Pap Exam at least every 3 years for women. Prostate specific antigen (PSA) test every year for men

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply) A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive Disorders

A.C.D.E. Eye examination every 1 to 3 years. DXA screening for osteoporosis, increase intake of the carbohydrate in the diet, screening for depressive disorders

A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply) A. Increase protein intake to increase muscle mass B. Decrease fluid intake to prevent urinary incontinence C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation

A.C.D.E. Increase protein intake to increase muscle mass; increase calcium intake to prevent osteoporosis, limit sodium intake to prevent edema, increase fiber intake to prevent constipation

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply) A. Have your working hours changed recently B. Do you feel confused in the later afternoon C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep E. Tell me about any personal stress you are experiencing

A.C.D.E. Job changes, including roles and working hours, can affect the quality and quantity of sleep. Caffeinated drinks act as a stimulant and can interfere with sleep. Periods of apnea warrant a prompt referral for diagnostic sleep studies. Emotional stress is a common cause of short term sleep problems

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. A. Hemostasis occurs immediately after the initial injury. B. A liquid called exudate is formed during the proliferation phase C. White blood cells move to the wound in the inflammatory phase D. Granulation tissue forms in the inflammatory phase E. During the inflammatory response, the patient has generalized body response F. A scar forms during the proliferation phase

A.C.E Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mild elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar

A nurse is promoting body movements for a patient during range of motion exercises. Which movements provide for flexion? (Select all that apply) A. Bending the hand or foot backward and forward B. Turning the sole of the foot toward the midline, then turning the sole of the foot outward C. Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position D. Curling the toes downward and then straightening them out E. Moving the head from side to side, then bringing the chin toward each shoulder F. Extending the leg and lifting it upward, then returning the leg to the original position

A.C.E. Bending the hand or foot backward and forward. Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position . Moving the head from side to side, then bringing the chin toward the shoulder

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? (Select all that apply) A. Caries may exist in the teeth, resulting from the failure to remove plaque. B. Gingivitis may be present involving the alveolar tissues C. Hard deposits of tarter may be found on the teeth if plaque is allowed to build up. D. Stomatitis may be noted as an inflammation of the tongue E. Cheliosis may present as reddened fissures at the angles of the mouth. F. Oral malignancies may be present in the form of a dry oral mucosa

A.C.E. Caries may exist in the teeth, resulting from the failure to remove plaque. Hard deposits of tarter may be found on the teeth if plaque is allowed to build up. Cheliosis may present as reddened fissures at the angles of the mouth

What are appropriate nursing measures when caring for a patient's eyes and ears? (Select all that apply) A. Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth, cottonball or compress. B. Use artificial tear solution or normal saline twice a day when the blink reflex is decreased or absent. C. Use a protective shield if necessary to keep the lids closed when the blink reflex is absent D. Use boric acid to remove excess secretions from the eyes E. Clean the patient's external ear with a wash cloth covered finger F. Use cotton tipped swabs to clean the inner ear and to remove cerumen

A.C.E. Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cottonball; or compress. Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. Clean the patient's external ear with a wash cloth covered finger

The nurse is managing the environment for patients on a busy hospital ward. Which interventions would the nurse perform to facilitate a more restful environment? (Select all that apply) A. Maintain a brighter room during daylight hours and dim lights in the evening B. Keep the room warm and provide earplugs and eye masks if requested C. Decrease the volume on alarms, pages, telephones, and staff conversations D. Schedule procedures separately to avoid tiring out patients E. Medicate for pain if needed F. Keep the doors to the patients room open

A.C.E. Maintain a brighter room during daylight hours and dim lights in the evening. Decrease the volume on alarms, pages, telephones, and staff conversations. Medicate for pain if needed

A nurse is providing foot care for patients in a long term care facility. Which actions are recommended guidelines for this procedure? Select all that apply A. Bathe the feet thoroughly in a mild soap and tepid water solution. B. Soak the feet in warm water and bath oil C. Dry feet thoroughly, including the area between the toes D. Use an alcohol rub if the feet are dry E. Use an anti fungal foot powder if necessary to prevent fungal infections F. Cut the toenails st the lateral corners when trimming

A.C.E. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an anti fungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

A school nurse is assessing school aged children for developmental milestones. Which students would be a concern for the nurse? (Select all that apply) A. An 8 year old student who is not writing with a pencil B. A 10 year old student who has not begun puberty C. A 12 year old student who still has baby teeth D. A 9 year old student who has not developed a set of values E. An 8 year old student whose height hasn't changed since preschool F An 11 year old student who is not developing skills for physical games

A.C.E.F. An 8 year old student who is not writing with a pencil. A 12 year old student who still has baby teeth. An 8 year old student whose height hasn't changed since preschool. An 11 year old student who is not developing skills for physical games

The nurse caring for infants in a hospital nursery knows that newborns continue to grow and develop according to individual growth patterns and development levels. Which terms describe these patterns? (select all that apply) A. Orderly B. Simple C. Sequential D. Unpredictable E. Differentiated F. Integrated

A.C.E.F. Growth and development are orderly and sequential, as well as continuous and complex. Growth and development follow regular and predictable trends, and are both differentiated and integrated.

When caring for older adults, nurses must be aware of common conditions found in this population. Which statements accurately describe these conditions? (Select all that apply) A. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark B. Delirium is a permanent state of confusion occurring in older adulthood C. Depression is a prolonged or extreme state of sadness occurring in many older adults D. As many as 50% of adults 65 years and older experience an episode of delirium during a hospitalization E. Polypharmacy is a term that is used to describe the habit of older adults to use many pharmacies to obtain their prescription drugs F. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences

A.C.F. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark. Depression is prolonged or extreme state of sadness occurring in many older adults. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health onsequences

A nurse is providing range of motion exercises for a 53 year old female patient who is recovering from stroke. During the session, the patient complains that she is "too tired to go on" What would be the priority nursing actions for this patient? A. Stop performing the exercises B. Decrease the number of repetitions performed C. Re-evaluate the nursing plan of care D. Move to the patient's other side to perform exercises E. Encourage the patient to finish the exercises and then rest. F. Assess the patient for other symptoms

A.C.F. When a patient complains of fatigue during range of motion exercises, the nurse should stop the activity, re-evaluate the nursing plan of care, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. A. Compare bilateral parts for symmetry. B. Proceed in a toe-to-head systematic manner. C. Use standard terminology to report and record findings. D. Do not allow data from the nursing history to direct the assessment. E. Document only skin abnormalities on the patient record. F. Perform the appropriate skin assessment when risk factors are identified.

A.C.F. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head to toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? Select all that apply A. Cover the area with saline soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply gentle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client warm beverage, such as herbal tea

A.D. Cover the area with saline-soaked sterile dressings- Cover the wound with a sterile dressing soaked with normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene Position the patient supine with the hips and knees bent. This position minimizes pressure on the abdominal area

A nurse is instructing a client who has an injury of the lower left extremity, about the use of a cane. Which of the following instructions should the nurse include? Select all that apply A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38cm (15in) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly with the cane

A.D. Hold the cane on the right side. The client should hold the cane on the uninsured side to provide support for the injured left leg. After advancing the cane, move the weaker leg forward; followed by the stronger leg

A nurse is caring for a client who is at risk for a pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply) A. Keep the head of the bed elevated 30degrees B. Massage the patient's bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hours while in bed

A.D. Keep the head of the bed elevated 30 degrees- Slightly elevate the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. Have the client sit on a gel cushion when in a chair- Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas

A nurse is preparing an extensive exercise program fro a 65 year old male patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? (Select all that apply) A. Instruct the patient to avoid sudden position changes that may cause dizziness. B.Recommend that the patient restrict fluid until after exercising is finished C. Instruct the patient to push a little further beyond fatigue each session D. Instruct the patient to avoid exercising in the very cold or very hot temperatures E. Encourage the patient to modify exercise if weak or ill F. Recommend that the patient consume a high carb, low protein diet

A.D. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoid extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if week or ill. Older adults should consume a high protein, high calcium, and vitamin D enriched diet

A nurse is teaching parents of preschoolers what type of behavior to expect from their children based on developmental theories. Which statements describe this stage of development? (Select all that apply) A. According to Freud, the child is in the phallic stage. B. According to Erickson, the child is in the trust vs. mistrust stage. C. According to Havighurst, the child is learning to get along with others. D. According to Fowler, the child imitates religious behavior of others E. According to Kohlberg, the child defines satisfying acts as right. F. According to Havighurst, the child is achieving gender specific roles

A.D.E. According to Freud, the child is in the phallic stage. According to Fowler, the child imitates religious behaviors of others. According to Kohlberg, the child defines satisfying acts as right. According to Erickson, the child is in the initiative vs. guilt stage. According to Havighurst, the child is learning sex differences, forming concepts, and getting ready to read. According to Havighurst, the adolescent, not the preschooler, is achieving gender-specific roles

One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? (Select all that apply) A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysm D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to an accident that occurred last year. F. A patient is experiencing pain from second degree burns

A.D.E. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns

A nurse assessing patient wounds would document which examples of wounds as healing normally without complications? Select all that apply. A. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges B. A wound that takes approximately 2 weeks for the edges to appear normal and heal together C. A wound with increased swelling and drainage that may occur during the first 5 days of the wound healing process D. A wound that does not feel hot upon palpation. E. A wound that forms exudate due to the inflammatory response. F. Incisional pain during the wound healing, which is most seer for the first 3 to 5 days and then progressively diminishes

A.D.E. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. A wound that does not feel hot upon palpation. A wound that forms exudate due to the inflammatory response

Which nursing interventions reflect the accurate use of heat or cold during wound care? (Select all that apply) A. The nurse makes more frequent checks of the skin of an older adult using a hating pad B. The nurse places a heating pad on a sprained wrist that is in the acute stage C. The nurse instructs the patient to lean or lie directly on the heating device D. The nurse fills an ice bag with small pieces of ice to about two thirds full E. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm F. The nurse applies moist cold to a patient's eye for 40 minutes every 2 hours

A.D.E. The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply A. For male and female patients, wash the groin area with a small amount of soap and water and rinse B. For a female patient, spread the labia and move the washcloth from the anal area to the pubic area C. For male and female patients, always proceed from the most contaminated area to the least contaminated area. D. For male and female patients, use a clean portion of the washcloth for each stroke E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward F. In an uncircumcised male patient do not retract the foreskin (prepuce) while washing the penis

A.D.E. Wash and rinse the groin area (both male and female) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male (teenager or older), retract the foreskin while washing the penis

A nurse is assessing neonates in a hospital nursery. Which neonates are exhibiting normal characteristics? (Select all that apply) A. A neonate displays the Moro and stepping reflex B. A neonate's body temperature responds slowly to environmental temperature C. A neonate's senses are not developed enough to feel pain from a heel stick. D A neonate eliminates urine and stool E. A neonate exhibits both an active state and a quiet alert state F. The neonate inherits a transient immunity from infections from the mother

A.D.E.F. A neonate displays the Moro and stepping reflex. A neonate eliminates urine and stool. A neonate exhibits both and active state and quiet alert state. The neonate inherits a transient immunity from infections from the mother

The nurse is providing a patient teaching for the parents of an obese child diagnosed with obstructive sleep apnea. What treatment measures would the nurse explain during the teaching session? (Select all that apply) A. A weight loss plan B. Treatment with intranasal antibiotics C. Treatment with sleeping pills D. Use of a continuous passive airway pressure machine E. Counseling for depression F. Use of a mandibular advancement device (MAD)

A.D.F. A weight loss plan. Use of a continuous passive airway pressure machine. Use of a mandibular advancement device

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? Select all that apply A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 minutes C. It is difficult to awaken a person in REM sleep D. Sleepwalking occurs during REM sleep E. Vivid dreams are common during REM sleep

A.E. Cognitive and brain tissue restoration occur during REM sleep. Dreaming does occur in other stages, but it is less vivid and possibly less colorful

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? Select all that apply A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A.E. Stage 3 pressure injury- Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges Open Burn area heals by secondary intention

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply A. Wash the skin twice a day with mild cleanser and warm water B. Use cosmetics liberally to cover blackheads C. Use emollients on the area D. Squeeze blackheads as they appear E. Keep hair off the face and wash hair daily F. Avoid sun tanning booth exposure and use sunscreen

A.E.F Washing the skin removes oils and debris, hair should be kept off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection

Which body system effects would the nurse state as occurring due to immobility? (Select all that apply) A. Increased cardiac workload B. Increased depth of respiration C. Increased rate of respiration D. Decreased urinary stasis E. Increased risk for renal calculi F. Increased risk for electrolyte imbalance

A.E.F. Increased cardiac workload. Increase risk for renal calculi. Increased risk for electrolyte imbalance

Which teaching points would the nurse use to explain the development of pressure ulcers to patients and how to prevent them? (Select all that apply) A. Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue B. Most pressure ulcers occur over the trochanter and calcaneus C. Generally, a pressure ulcer will not appear within the first two days in a person who has not moved for an extended period of time. D. The major predisposing factor for a pressure ulcer is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues E. The skin can tolerate considerable pressure without cell death, but for short periods only F. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation

A.E.F. Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation

A nurse researcher studies the effects of genomics on current nursing practice. Which statements identify genetic principles that will challenge nurses to integrate genomics in their research, education, and practice? (select all that apply) A. Genetic tests plus family history have the potential to identify people at risk for certain diseases B. Pharmacogenetic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication C. Evidence based review panels are in place to evaluate the possible risks and benefits related to genetic testing D. Valid and reliable national data are available to establish baseline measures and track progress toward targets E. Genetic variation can either accelerate or slow the metabolism of many drugs F. It is beyond the role of the nurse to answer questions and discuss the impact of genetic findings on health and illness

AB.E. In the very near future, all health care providers will be challenged to integrate genomics into their research, education, and practice. Genetic tests plus family history tools have the potential to identify patients at risk for diseases. Pharmacogenetics is the study of how genetic variation affects an individuals response to drugs. Pharmacogenetic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from medication. Genetic variation can either accelerate or slow the metabolism of many drugs. Two emergency challenges related to genomic discoveries are (1) the need for evidence based review panels to thoroughly evaluate the possible benefits and harms related to the expanding number of genetic tests and family health history tools, and (2) valid and reliable national data are needed to establish baseline measures and track progress toward targets. Nurses must be prepared to answer questions and discuss the impact of genetic findings on health and illness.

A nurse is assessing the psychosocial development of children in a day care center. Which child would the nurse expect to be experiencing the most intense period of speech development? A. A 2 year old B. A 4 year old C. A 6 year old D. An 8 year old

B. A 4 year old

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: A. Stage I B. Stage II C. Stage III D. Stage IV

B. A Stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum filled blister

The nurse records an APGAR score of 4 for a newborn. What would be the priority intervention for this newborn? A. No interventions are necessary; this is a normal score B. Provide respiratory assistance. C. Perform CPR D. Wait 5 minutes and repeat the scoring process

B. A newborn who scores a 4 on the APGAR chart requires special assistance such as respiratory assistance. Normal APGAR scores are 7 to 10. Neonates who score between 4 and 6 require special assistance, and those who score below 4 are in need of life saving support

A nurse is caring for children in a children's hospital. Which child would the nurse expect to develop separation anxiety? A. An infant who was abandoned by his parents B. A newly hospitalized toddler C. A preschooler who is on an isolation ward D. A school aged child who has low self esteem

B. A newly hospitalized toddler

A nurse assesses a patient's body temperature in the late afternoon as 37.2(99). What would be the nurse's best action related to this slight elevation in temperature? A. Assess the patient for infection B. Record the temperature as a normal finding C. Call the physician for an order for antipyretics D. Decrease the room temperature

B. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm

The nurse instructs a patient to enter a hot whirlpool gradually. What is the theory that explains why a body part becomes acclimated to water temperature gradually? A. Threshold of pain theory B. Adaptation theory C. Gate control theory D. Regulation by neuromodulators

B. Adaptation theory

A nurse working with adolescents in a group home discusses the developmental tasks appropriate for adolescents with the staff. What is an example of a primary developmental task of the adolescent? A. Working hard to succeed in school B. Spending time developing relationships with peers C. Developing athletic activities and skills D. Accepting the decision of parents

B. Adolescence is a time to establish more mature relationships with both boys and girls of the same age

A nurse assisting with a patient bed bath observes that an older female patient has dry skin. The patient states that her skin is always itchy. Which nursing action would be the nurse's best response? A. Bathe the patient more frequently B. Use an emollient on the dry skin C. Massage the skin with alcohol D. Discourage fluid intake

B. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and subsequently, dry skin

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurses best intervention in this situation? A. Ignore the boys pain if he is not complaining about it B. Ask the boy to draw a cartoon about the color or shape of his pain C. Medicate the boy with analgesics to reduce the anxiety of experiencing pain D. Distract the boy so he doesn't notice his pain.

B. Ask the boy to draw a cartoon about the color or shape of his pain

A nurse is scheduling hygiene for patients on her unit. What is the most important consideration when planning a patient's personal hygiene? A. When the patient had his or her most recent bath. B. The patient's usual hygiene practices and preferences. C. Where the bathing fits into the nurse's schedule. D. The time that is convenient for the patient care assistance

B. Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them

B. Brush the dentures with a toothbrush and denture cleaner. Brushing the dentures thoroughly with a toothbrush and denture cleaner removes debris that accumulate on and between the teeth.

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A. A 4 month old infant who is unable to roll over B. A 6 month old who is unable to hold his head up himself C. An 11 month old who cannot walk unassisted D An 18 month old toddler who cannot jump

B. By 5 months head control is usually achieved. An infant rolls over by 6-9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump

A nurse is instructing a client who has narcolepsy about measures that might help with self management. Which of the following statements should the nurse identify as an indication that the client understands the instructions A. I'll add plenty of carbohydrates to my meals B. I'll take a short nap whenever I feel a little sleepy C. I'll make sure I stay warm when I am at my desk at work D. It's okay to drink alcohol as long as I limit it to one drink per day

B. Clients who have narcolepsy should take short naps to reduce feelings of drowsiness

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care

B. D. Chronic illness- Diabetes is a chronic illness that places additional stress on the body's healing mechanisms Malnutrition- A BMI of 17.1 indicates that the client is underweight and therefore malnourished. Deficiencies in essential nutrients delay wound healing

A nurse is caring for a client postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply) A. Instruct the client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein level D. Place pillows under the clients knees and lower extremities E. Assist the client to change positions often

B. E. Apply elastic stockings. Elastic stockings promote venous return and prevent thrombus formation. Assist the client to change positions often. Frequent position changes prevents venous stasis

A nurse is implementing a sex education program in a public school. With which grade level should the nurse begin the program? A. Kindergarten B. Elementary C. Middle school/junior high D. High school

B. Elementary

A nurse is counseling pregnant women about the detrimental effects of smoking and drinking on a fetus. During what stage of development is the fetus most susceptible to these teratogens? A. Preembryonic stage B. Embryonic stage C. Fetal stage D. Neonatal stage

B. Embryonic stage

A nurse is promoting exercise and activities for an elderly patient. Which teaching point would be appropriate for this patient? A. Encourage the patient to quickly increase the repetitions for arm and leg exercises B. Encourage the patient to warm up before beginning exercises and to cool down after exercising C. Instruct the patient to continue exercise even if feeling weakness, to build up stamina D. Teach the patient to force joints to meet their natural limit and beyond prior to modifying exercises

B. Encourage the patient to warm up before beginning exercises and to cool down after exercising

A patient is experiencing acute pain following the amputation of a limb. What nursing intervention would be most appropriate when treating this patient? A. Treat the pain only as it occurs to prevent drug addiction B. Encourage the use of non drug complementary therapies as adjuncts to the medical regimen C. Increase and decrease the serum level of the analgesic as needed D. Do not provide analgesia if there is any doubt about this likelihood of pain occurring

B. Encourage those of non drug complementary therapies as adjuncts to the medical regimen

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

B. For a patient who has footdrop, the nurse should support the feet in dorsiflexion, and use a footboard or high top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

When caring for a patient with insomnia, the nurse would appropriately institute which intervention>? A. Encourage the patient to nap frequently during the day to make up for the lost sleep at night B. Have the patient eliminate caffeine and alcohol in the evening because both are associated with disturbance in the normal sleep cycle. C. Advise the patient to exercise vigorously before bedtime to promote drowsiness D. Advise the patient to avoid food high in carbohydrates before bedtime

B. Have the patient eliminate caffeine and alcohol in the evening because both are associated with disturbance in the normal sleep cycle

When assessing pain in a child, the nurse needs to be aware of what considerations? A. Immature neurologic development result in reduced sensation of pain. B. Inadequate or inconsistent relief of pain is widespread C. Reliable assessment tools are currently unavailable D. Narcotic analgesci use should be avoided

B. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored

A nurse is caring for a 52 year old male patient who is being treated for depression following the death of his spouse. Which action best facilitates the accomplishment of a developmental task of this middle adult? A. Encouraging him to start dating again to find a life partner B. Helping him to see the value of guiding his children to become responsible adults C. Helping him to establish a social network within the community D. Encouraging the formation of a personal philosophical and ethical structure.

B. Helping him to see the value of guiding his children to become responsible adults

A nurse notes that a patient admitted to a long term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this patient's brain may have suffered damage? A. Cerebral cortex B. Hypothalamus C. Medulla D. Midbrain

B. Hypothalamus

A nurse is caring for an 82 year old woman in a long term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? A. Improved renal blood supply to the kidneys B. Urinary stasis C. Decreased urinary calcium D. Acidic urine formation

B. In a nonerect patient, the kidneys and ureter are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder resulting in urinary stasis. Urinary stasis favors the growth of bacteria that can cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. I already had my immunizations as a child, so I'm protected in that area B. It is important to schedule routine health care visits even if I am feeling well C. I will just go to an urgent care center for my routine medical care D. There's no reason to seek help if I am feeling stressed because it's just a part of life

B. It is important to schedule routine health care visits even if I am feeling well

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. I am struggling to accept that my parents are aging and need so much help B. It's been so stressful for me to think about having intimate relationships C. I know I should volunteer my time for a good cause, but maybe Im just selfish D.I love my grandchildren but my son expects me to relive my parenting days

B. It's been so stressful for me to think about having intimate relationships

Based on Erickson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which statement is one example of this finding? A. I am helping my parents move into an assisted living facility B. I spend all of my time going to the doctor to be sure I am not sick C. I have enough money to help my son and his wife when they need it D. I earned this gray hair and I like it

B. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs

A patient diagnosed with hypothyroidism is suffering from fatigue, lethargy, depression and difficulty executing the tasks of everyday living. What type of sleep deprivation would the nurse suspect is affecting this patient? A. REM deprivation B. NREM deprivation C. Total sleep deprivation D. Insomnia

B. NREM deprivation

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A. REM behavior disorder B. Narcolepsy C. Enuresis D. Sleep apnea

B. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by acting out dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? A. Encouraging regular use of analgesics B. Applying a moist heating pad to the area at prescribed intervals C. Reviewing the pain experience with the patient D. Ambulating the patient after administering medication

B. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control therapy

Which nursing action would help maintain safety in the older adult? A. Treat each patient as a unique individual B. Orient the patient to new surroundings C. Encourage independence D. Provide planned rest and activity times

B. Orient the patient to new surroundings

A nurse caring for older adults in a long term care facility is teaching a novice nurse characteristic behaviors of older adults? Which statement is not considered ageism? A. Old age begins at age 65 B. Personality is not changed by chronological aging C. Most older adults are ill and institutionalized D. Intelligence declines with age

B. Personality is not changed by chronological aging

A new patient in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is: Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis? A. Help the patient maintain normal bedtime routine and time for sleep B. Provide an opportunity for the patient to talk about concerns C. Use tactile relaxation techniques, such as a back massage D. Bring the patient a warm glass of milk at bedtime

B. Provide an opportunity for the patient to talk about concerns

After assessing a female adolescent, a nurse collects the following data: development of breast tissue, growth spurt in height and weight, appearance of axillary hair, and initiation of menarche. Which stage of development does this data confirm A. Prepubescence B. Pubescence C. Post pubescence D. Precocious puberty

B. Pubescence

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red". What would be the priority nursing intervention for this type of wound? A. Irrigate the wound B. Provide gentle cleansing of the wound C. Debride the wound D Change the dressing frequently

B. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wound in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary and/or based on manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal

The nurse is performing range of motion exercises on a patient's arm. The nurse starts by lifting the arm forward to above the head of the patient. Which action would the nurse perform next? A. Move the opposite arm forward to above the head of the patient B. Return the arm to the starting position at the side of the body C. Rotate the lower arm and hand so the palm is up D. Move the arm across the body as far as possible

B. Return the arm to the starting position at the side of the body

Which nursing action is appropriate when providing foot care for a patient? A. Soak the feet in a solution of mild soap and tepid water B. Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms C. For diabetic patients, trim the nails with clippers D. Cut off any corns and calluses

B. Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms

A nurse is caring for an 80 year old patient who has become weak and fatigued easily. He is unable to wash his body and always asks his nurse to brush his teeth. Based on this information, what is an appropriate nursing diagnosis? A. Risk for Impaired Skin Integrity related to immobility B. Bathing/Hygiene Self Care Deficit related to decreased strength and endurance C. Social Isolation related to a lack of visitors D. Impaired Oral Mucous Membrane related to inability to brush his teeth

B. Risk for Impaired Skin Integrity, Social Isolation, and Impaired Oral Mucous Membrane may be appropriate nursing diagnoses for this patient. However, not enough is known, based on the information given, to formulate these diagnoses. The priority at this time, based on the given information, is Bathing/Hygiene Self Care Deficit

A nurse is assessing and diagnosing children in a pediatrician's office. Which diagnosis would be most appropriate for a school aged child? A. Disturbed personal identity B. Risk for infection C. Risk prone health behavior D. Risk for poisoning

B. Risk for infection

When assessing a patient receiving a continuous opioid infusion, a nurse immediately notifies the physician when the patient has: A. A respiratory rate of 10/min with normal depth B. A sedation level of 4 C. Mild confusion D. Reported constipation

B. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and the disappear, additional observation is necessary. Constipation should be reported to they physician, but is not the priority in this situation

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should this nurse use for safe care of this client A. Supine B. Semi Fowler's C. Semi prone D. Trendelenburg

B. Semi Fowlers. In the semi Fowler's position, the client lies supine with the head of the bed elevated 15-45 degrees (typically 30). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings

The nurse encourages parents of hospitalized infants and toddlers to stay with their child to help decrease what potential problem? A. Problems with attachment B. Separation anxiety C. Risk for injury D. Failure to thrive

B. Separation anxiety, with crying initially and then appearing depressed, is common during late infancy in infants who are hospitalized

A nurse attempts to wake a patient who is scheduled for tests and is able to arouse him relatively easy. Which stage of sleep is this patient most likely experiencing? A. Stage I B. Stage II C. Stage III C. Stage IV

B. Stage II

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV

B. Stage II

A nurse is performing range of motion exercises on a patient who is on bedrest. What would be the nurse's best action when the patient complains: "I'm just too tired to do these exercises today." A. Encourage the patient to finish the exercises and then reevaluate the nursing plan B. Stop the exercises and reevaluate the nursing plan of care. C. Finish the exercises and report the incident to the primary care provider D. Modify the number of repetitions for each exercise and then modify the plan

B. Stop the exercises and reevaluate the nursing plan of care

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A. Keep the room light dimmed during the day B. Keep the room cool C. Keep the door of the room open D. Offer a sleep aid medication to patients on a regular basis

B. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medication should only be offered as prescribed

A 17 year old has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point to the patient? A. Use the axillae to bear body weight B. Keep elbows close to the sides of the body C. When rising, extend the uninjured leg to prevent weight bearing D. To climb stairs, place weight on the affected leg first

B. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing the stairs

A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? A. Cutaneous B. Visceral C. Superficial D. Somatic

B. The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (Superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is and example of cutaneous pain. Deep somatic pain is diffuse, or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of an 80 year old hospitalized female patient. During the patient interview the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6

B. The total score for this patient is 4. On the Katz index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding

A nurse is evaluating a clients understanding of the use of a sequential compression device. Which of the following client statements indicates the client understanding? A. This device will keep me from getting sores on my skin B. This device will keep the blood pumping through my leg C. With this device, my leg muscles won't get weak D. This device is going to keep my joints in good shape

B. This device will keep the blood pumping through my leg. Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation

A female patient who is being treated for self inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk? A. Albumin level 3.5mg/dL B. Total lymphocyte count of 1500/mm^3 C Body weight decrease of 5% D. Arm muscle circumference 90% of standard

B. Total lymphocyte count of 1500/mm^3

When bathing a patient, the nurse notices that the patient has a rash on her arms. What would be an appropriate nursing intervention? A. Avoid washing the area because cleansing agents will only make the rash worse B. Use a tepid bath to relieve inflammation and itching C. Do not use over the counter products on unknown rashes D. Use a moisturizing lotion on a wet rash to prevent itching

B. Use a tepid bath to relieve inflammation and itching

A nurse is caring for a 25 year old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for the patient's piercings? A. Do not remove or wash the piercings without permission from the patient B. Rinse the sites with warm water and remove crusts with a cotton swab C. Wash the sites with alcohol and apply antibiotic ointment D. Remove the jewelry and allow the sites to heal over

B. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing all crusts with a cotton swab. The nurse should then apply a dab of liquid medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary. (E.g when an MRI is ordered)

A nurse is using the RYB wound classifications system to document patient wounds. Which wounds would the nurse document as a Y (yellow wound) Select all that apply A. A wound that reflects the color of normal granulation tissue B. A wound that is characterized by oozing from the tissue covering the wound C. A wound with drainage that is a beige color D. A wound that requires wound cleaning and irrigation E. A wound that is covered with thick eschar F. A wound that is treated by using sharp, mechanical, or chemical debridement

B.C.D. A wound that is characterized by oozing from the tissue covering the wound. A wound drainage that is a beige color. A wound that requires cleaning and irrigation

A nurse is teaching a patient about the beneficial effects of exercise on his body. Which teaching point would the nurse include in the plan? (Select all that apply) A. Exercise increases resting heart rate and blood pressure B. Exercise increases intestinal tone C. Exercise increases efficiency of metabolic system D. Exercise increases blood flow to the kidneys E. Exercise decreases appetite F. Exercise decreases rate of carbon dioxide excretion

B.C.D. Exercise increases intestinal tone. Exercise increases efficiency of metabolic system. Exercise increases blood flow to the kidneys

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply) A. Install bath rails and grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from home

B.C.D. Wearing a helmet while skiing, Install a carbon monoxide detector, secure firearms in a safe location

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B.C.D.E. Pneumococcal immunization, yearly eye examination, periodic mental health screening, annual fecal occult blood test

A nurse is developing a plan of care of an 86 year old woman who has been admitted for a right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? select all that apply. A. The patient takes time to think about her responses to questions B. The patient's age of 86 years C. Patient reports inability to control urine D. A scheduled hip arthroplasty E. Lab findings include BUN 12 (elderly normal is 8-23mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL F. Patient reports increased pain in right hip when repositioning in bed or chair

B.C.D.F Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patient's for foot and nail problems. Which patient would be at higher risk? Select all that apply A. A patient who is taking antibiotics for chronic bronchitis B. A patient diagnosed with Type II diabetes C. A patient who is obese D. A patient who has a nervous habit of biting his nails E. A patient diagnosed with prostate cancer F. A patient whose job involves frequent hand washing

B.C.D.F Variables known to cause nail and foot problems include deficient self care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals, or water, trauma, ill fitting shoes, and obesity

The nurse recognizes common pain syndromes that cause neuropathic pain. Which patients would the nurse place at risk for this type of pain? (select all that apply) A. A patient who has a tooth abscess. B. A patient with postherpetic neuropathy C. A patient with phantom limb pain D. A patient t with diabetic neuropathy E. A patient who has lung cancer F. A patient with complex regional pain syndrome.

B.C.D.F. A patient with postherpetic neuralgia. A patient with phantom limb pain. A patient with diabetic neuropathy. A patient with complex regional pain syndrome

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? Select all that apply. A."My line of gravity should fall outside my base of support" B. "The lower my center of gravity, the more stability I have" C. "To broaden my base of support, I should spread my feet apart" D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling on object, I should move my front foot forward."

B.C.E The lower my center of gravity the more stability I have. Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. To broaden my base of support I should spread my feet apart. Spreading the feet apart increases and widens the base of support. When I lift an object I should hold it as close to my body As possible. Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury band instability.

Which nursing actions would the nurse perform when assisting patients with passive ROM exercises? (Select all that apply) A. Raise the bed to the highest position B. Adjust the bed to the flat position or as low as the patient can tolerate C. Begin ROM exercises at the patient's head and move down one side of the body at a time D. Perform each exercise 10 to 15 times E. Move each joint in a smooth, rhythmic manner F. Use a flat palm to support joints during ROM exercises

B.C.E. Adjust the bed to the flat position or as low as the patient can tolerate. Begin ROM exercises at the patient's head and move down one side of the body at a time. Move each joint in a smooth, rhythmic manner

A nurse is assessing infants during regular visits to a pediatrician's office. What are normal physical characteristics of an infant? (Select all that apply) A. Brain grows to about one-third the adult size B. Body temperature stabilizes C. Eyes begin to focus and fixate D. Heart triples in weight E. Heart rate slows and blood pressure rises F. Birth weight usually doubles by 1 year

B.C.E. Body temperature stabilizes. Eyes begin to focus and fixate. Heart rate slows and blood pressure rises

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply A. A patient who is taking iron supplements for anemia B. A patient with Parkinson disease who is taking dopamine C. An elderly patient taking diuretics for congestive heart failure D. A patient who is taking antibiotics for an ear infection E. A patient who is prescribed antidepressants F. A patient who is taking low dose aspirin prophylactically

B.C.E. Drugs that decrease REM sleep include barbituates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidrepressants, and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply) A. Develop an acceptance of diminished strength and increased dependence on others B. Spend time focusing on improving job performance C. Welcome opportunities to be creative and productive D. Commit to finding friendship and companionship E. Become involved with community issues and activities

B.C.E. Spend time focusing on improving job performance. Welcome opportunities to be creative and productive. Become involved with community issues and activities

A nurse explains cognitive behavioral therapy (CBT) to a patient who is experiencing chronic insomnia. Which statements by the nurse best describe this therapy? (Select al that apply) A. Sedative and hypnotics are used in conjunction with CBT B. You will meet with a therapist to work through any maladapative sleep beliefs. C. Used with other complementary therapies, CBT is very successful D. Pharmacological approaches should be attempted prior to CBT to resolve the insomnia E. CBT may include progressive muscle relaxation measures, stimulus control, and sleep restriction therapies F. Patients undergoing CBT are asked to stay in bed during normal sleep hours even if they are unable to sleep

B.C.E. You will meet a therapist to work through any maladaptive sleep beliefs. Used with other complementary therapies, CBT is very successful. CBT may include progressive muscle relaxation measures, stimulus control, and sleep restriction therapies

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do what actions? Select all that apply A. Do full body pushups in bed six to eight times daily B. Breathe in and out smoothly during quadriceps drills C. Place the bed in the lowest position or use a footstool for dangling D. Dangle on the side of the bed for 30 to 60 minutes E. Allow the nurse to bathe the patient completely to prevent fatigue F. Perform quadriceps 2 to 3 times per hour, 4 to 6 times per day.

B.C.F Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps 2 to 3 times per hour, 4 to 6 times per day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.) A. Symptoms of wound infection, which are usually apparent within 1 to 2 weeks after the injury or surgery B. Dehiscence, which is present when there is a partial or total disruption of wound layers C. Evisceration, which occurs when the viscera protrudes through the incisional area D. Delayed wound healing in patients who are thin and at greater risk for complications owing to a thinner layer of tissue cells E. A wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5, which is a sign of an impending evisceration F. Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site

B.C.F. Dehiscence, which is present when there is a partial of total disruption of wound layers. Evisceration, which occurs when the viscera protrudes through the incisional area. Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? (Select all that apply) A. Pain is whatever the physician treating the pain says it is. B. Pain exists whenever the person experiencing it says it exists C. Pain is an emotional and sensory reaction to tissue damage D. Pain is a simple, universal and easy to describe phenomenon E. Pain that occurs without a known cause is psychological in nature F. Pain is classified by duration, location, source, transmission, and etiology

B.C.F. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients. "Pain is whatever the experiencing person says it is, existing whenever he or she says it does." The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology

Which actions would a nurse be expected to perform when applying a saline moistened dressing to a patient's wound? Select all that apply A. Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound B. Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end C. Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape D. Apply one dry, sterile gauze pad over the wet gauze and then place an ABD pad over the gauze pad E. Using clean technique, open the supplies and dressings and place the fine mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it F. Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton tipped applicators to press gauze into all wound surfaces

B.C.F. Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. Carfully and gently remove the soiled dressings; if there is resistance, use a silicone based adhesive remover to help remove tape. Gently press to loosely pack the moistened gauze into the wound; if necessary use forceps or cotton tipped applicators to press gauze into all wound surfaces

A nurse is assessing a patient's mobility status. What data would the nurse document as normal findings? (Select all that apply) A. Increased joint mobility B. Independent maintenance of correct alignment C. Scissors gait D. Head, shoulders, and hips aligned in bed E. Full range of motion F. Fasciculations

B.D.E Independent maintenance of correct alignment. Head, shoulders, and hips aligned in bed. Full range of motion

A nurse is assessing toddlers in a community health care clinic. Which toddlers would the nurse refer for follow up care? (Select all that apply) A. A 2 year old whose birth weight quadrupled B. A 2 year old who cannot kick a ball C. A 3 year old who is drawing stick figures D. A 1.5 year old whose arms and legs are not increasing in length E. A 1 year old who does not pick up small objects with fingers F. A 1 year old who does not have bladder control during the day

B.D.E. A 2 year old who cannot kick a ball. A 1.5 year old whose arms and legs are not increasing in length. A 1 year old who does not pick up small objects with fingers

The nurse is teaching a patient about non-pharmacologic measures to alleviate restless leg syndrome (RLS). Which teaching points would the nurse include in her plan? (select all that apply) A. Drinking a cup of coffee before bed can help relieve the tingling sensations. B. Applying heat or cold to the extremity can help relieve the symptoms C. An alcoholic drink is recommended before bed to relax a patient D. Biofeedback and TENS can help relax the patient and relieve symptoms E. Massaging the legs may relieve symptoms F. A mild analgesic before bed can help relieve symptoms

B.D.E. Applying heat or cold to the extremity can help relieve the symptoms. Biofeedback and TENS can help relax the patient and relieve symptoms. Massing the legs may relieve symptoms

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging (Select all that apply) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

B.D.E. Decreased height, nail thickening, decreased bladder capacity

The nurse is massaging an elderly patient's back and notices a reddened area on the patient's sacrum. What actions would the nurse perform in response? (select all that apply) A. Lightly massage the area B. Document the reddened area on the patient medical record C. Following the massage, position the patient on the sacral area D. Report the finding to the primary care provider. E. Institute a turning schedule. F. Do not massage the patient's back, immediately report the area to the physician.

B.D.E. Document the reddened area on the patient medical record. Report the finding to the primary care provider. Institute a turning schedule.

A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? (Select all that apply) A. A patient's increased skin elasticity causes wrinkles on the face and arms B. Exposure to sun over the years causes a patient's skin to be pigmented C. A patient's toenail have become thinner with a bluish tint to the nail beds D. A patient experiences a hip fracture due to porous and brittle bones E. Fragile blood vessels in the dermis allow for more easy bruising of a patient's forearm F. Increased bladder capacity causes decreased voiding in an older patient

B.D.E. Exposure to sun over the years can cause a patient's skin to be pigmented. Bone demineralization occurs with aging, causing, bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase n bruising and purpura. Wrinkling and sagging of skin occur with decreased skin elasticity. A patient's toenails may become thicker, with a yellowish tint to the nailbeds. Bladder capacity decreases by 50% , making voiding more frequent; two to three times a night is usual

A nurse assesses the effect of the environment and nutrition on patients visiting a walk in clinic in a low income community. Which statements accurately describe these effects? (Select all that apply) A. Infants who are malnourished in utero develop the same amount of brain cells as infants who had adequate prenatal nutrition B. Substance abuse by a pregnant woman increases the risk for congenital anomalies in her developing fetus C. Failure to thrive cannot be linked to emotional deprivation D. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships E. An increased incidence of teenage pregnancy can be linked to substance abuse by adolescents F. Child abuse can lead to deficits in physical development but psychosocial development is not affected

B.D.E. Substance abuse by a pregnant woman increases the risk for congenital anomalies in her developing fetus. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships. An increased incidence of teenage pregnancy can be linked to substance abuse by adolescents

Which nursing actions are recommenced guidelines when performing oral care? (Select all that apply) A. Use a hard toothbrush to remove plaque from the teeth B. Ideally, brush teeth immediately after eating or drinking C. Never clean the tongue with a toothbrush D. If desired, use an automatic toothbrush to remove debris and plaque from teeth E. Never use water spray units to assist with oral hygiene F. If desired, use salt and sodium bicarbonate as cleaning agents for short term use

B.D.F. Ideally, brush teeth immediately after eating or drinking. If desired, use an automatic toothbrush to remove debris and plaque from teeth. If desired, use salt and sodium bicarbonate as cleaning agents for short term use

Following a fall that left an elderly male patient temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? (Select all that apply) A. S-Senility B. P-Problems with feeding C. I-Irritableness D. C-Confusion E. E-Edema of the legs F. S- Skin breakdown

B.D.F. The SPICES acronym is used to identify common problems in older adults and stands for S-Sleep disorders; P- Problems with eating or feeding; I- Incontinence; C- Confusion; E-Evidence of falls; S-Skin breakdown

Dorsiflexion

Backward bending of the hand or foot. (Example: A persons foot is in dorsiflexion when the toes are brought up as though to point them at the knee)

Most authorities agree that an individual's sleep wake cycle is fully developed by what age? A. 9 months to 1 year B. 1 year to 18months C. 2 to 3 years D. 4 to 6 years

C. 2 to 3 years

After sedating a patient, the nurse assesses that the patient is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this patient? A. 1 B. 2 C. 3 D. 4

C. 3

Which patient would the nurse place in a protective prone postion? A. A patient prone to internal shoulder rotation and adduction B. A patient prone to edema of the hand C. A patient prone to hyperextension of the spine D. A patient prone to flexion contracture of the neck

C. A patient prone to hyperextension of the spine

For which of the following patient's would the nurse be most likely to administer a benzodiazepine type drug? A. A patient who needs long term therapy for chronic insomnia B. A patient who has insomnia and awakens in the middle of the night C. A patient who is being treated for short term insomnia D. A patient who has insomnia combined with restless leg syndrome

C. A patient who is being treated for short term insomnia

A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? A. Most older adults live in their own homes B. Healthy older adults enjoy sexual activity C. Old age means mental deterioration D. Older adults want to be attractive to others

C. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes, an although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90's in healthy older adults. Older adults want to be attractive to others

What is the leading cause of cognitive impairment in old age? A. Stroke B. Malnutrition C. Alzheimer disease D. Loss of cardiac reserve

C. Alzheimer disease is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks

The nurse is assessing an ambulatory patient for gait. Which documentation describes this mobility status? A. A straight line can be drawn from the ear throught the shoulder and hip B. Patient displays full range of motion in arms and legs C. Arms swing freely in alternation with legs D. Adequate muscle mass, tone, and strength are available to accomplish movement

C. Arms swing freely in alternation with legs

A child who learns that he must sit quietly during story hour in kindergarten, thereby integrating this new experience into his existing schemata, is applying the process of: A. Accomadation B. Dissemination C. Assimilation D. Orientation

C. Assimilation

A nurse is caring for a child who states: I don't like the taste of this medicine, but my parents told me it will help me get better, so I'll take it. This example best exemplifies which stage of Piaget's cognitive development theory? A. Sensorimotor stage B. Preoperational stage C. Concrete operational stage D. Formal operational stage

C. Concrete operational stage

A nurse is providing teaching for an older adult client who has lost 4.5kg (9.9lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A. Eat three large meals a day B. Eat your meals in from of the television C Eat foods that are easy to eat, such as finger foods. D. Invite family members to eat meals with you E. Exercise every day to increase appetite

C. D.E. Eat foods that are easy to eat, such as finger foods; Invite family members to eat meals with you; exercise every day to increas appetite

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself sandwiched between and being responsible for two generations

C. Devoting a great deal of time to establishing and occupation

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? A.Pain B. Impaired skin integrity C. Disturbed Body Image D. Disturbed thought processes

C. Disturbed body image- Wounds cause emotional as well as physical stress

The nurse is providing perineal care for patients in a hospital setting. What is an appropriate nursing action when providing this type of care? A. Always proceed from the most contaminated area to the least contaminated area. B. Do not retract the foreskin in an uncircumcised male C. Dry the cleaned areas and apply an emollient as directed D. Powder the area to prevent the growth of bacteria

C. Dry the cleaned area and apply an emollient as indicated

Erickson identified ego integrity vs despair and disgust as the last stage of human development, which begins at about 60 years of age. Which intervention would best foster older patients' ego integrity? A. Distracting the patient B. Praising the patient C. Encouraging life review D. Promoting independent living

C. Encouraging life review

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? A. Prostaglandins B. Substance P C. Endorphins, D. Serotonins

C. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain blocking chemicals that have prolonged analgesic effects and and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles inhibit gastric secretion and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells

A nurse is caring for a 73 year old patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent position B. Lateral position C. Fowler's position D. Sim's position

C. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or sim's position would not facilitate respiration and would be difficult for the patient to maintain

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow" B. "Have your head turned to the side while you lie on your stomach" C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table" D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

C. Have a table beside your bed so you can sit on the bedside and rest your arms on the table. This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD

A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. I have my own apartment now, but it's not easy living away from my parents B. It's been so stressful for me to even think about having my own family C. I don't even know who I am yet, and now I'm supposed to know what to do. D. My girlfriend is pregnant and I don't think I have what it takes to be a good father

C. I don't even know who I am yet, and now I'm supposed to know what to do

A nurse is caring for a patient who us receiving morphine via a patient controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. I'll wait to use the device until it is absolutely necessary B. I'll be careful about pushing the button too much so I don't get an overdose C. I should tell the nurse if the pain doesn't stop while I am using this device D. I will ask my adult child to push the button when I am sleeping

C. I should tell the nurse if the pain doesn't stop while I am using this device

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? A. Wait a few minutes and then continue the move to the chair B. Call for assistance and continue the move with the help of another nurse C. Lower the patient back to the side of the bed and pivot her back into bed D. Have the patient sit down on the bed and dangle her feet before moving

C. If the patient becomes faint and knees buckle when moving from bed to chair, the nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member of vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to the change in position, and avoid hypotension related to a sudden change in position

The nurse is teaching an adolescent how to treat acne? What would the nurse include as a teaching point? A. Gently squeeze the infected areas to release the infection B. Wash your face less frequently to avoid removing beneficial oils C. Keep hair off the face and wash hair daily D. Use cosmetics and emollients to cover the condition

C. Keep hair off the face and wash hair daily

A nurse is assessing middle adults living in a retirement community. What behavior would the nurse typically see in the middle adult? A. Believes in establishment of self nut fears being pulled back into family B. Usually substitutes new roles for old roles and perhaps continues formal roles in a new context C. Looks inward, accepts lifespan as having definite boundaries, and has special interest in spouse, friends, and community D. Looks forward but also begins to reflect on his or her life

C. Looks inward, accepts lifespan as having definite boundaries, and has special interest in spouse, friends, and community

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue C. The therapy provides a moist environment an stimulates blood flow to the wound D. The therapy irrigates the wound to keep it free from debris and excess wound fluid

C. Negative pressure wound therapy (or topical negative pressure[TNP]) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and then the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain B. Question the client about the location of the pain C. Offer the client a pain scale to measure his pain D. Use open-ended questions to identify the client's pain sensations

C. Offer the client a pain scale to measure his pain

A patient complains of severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this patient? A. NSAIDS B. Corticosteroids C. Opioid analgesics D. Nonopioid analgesics

C. Opioid analgesics

The school nurse is teaching parents of adolescents about the development of self concept in their children. What would the nurse state is most influential in stabilizing self concept in this age group? A. Parents B. Siblings C. Peers D. Teachers

C. Peers

A nurse examining a toddler in a pediatric office documents that the child is in the 90th percentile for height and weight and has blue eyes. These physical characteristics are primarily determined by: A. Socialization with other caregivers B. Maternal nutrition during pregnancy C. Genetic information on chromosomes D. Meeting developmental tasks

C. Physical appearance and growth have a predetermined genetic base in inheritance patterns carried on the chromosomes

A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be developmentally appropriate for this age group? A. Playing video games B. Playing peek a boo C. Playing in a sandbox D. Playing board games

C. Playing in a sandbox with toys that emphasize gross motor skills and creativity is a developmentally appropriate activity for a toddler. Video games are appropriate for school aged children and adolescents, but should be monitored. Playing peek a boo is developmentally appropriate for an infant and playing board games usually begins with preschool and older children

Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes? A. Using hydrogen peroxide B. Wiping from the outer canthus to the inner canthus C. Positioning him on the same side as the eye to be cleansed D. Using only one cotton ball per eye

C. Positioning the patient on the same side as the involved eye discourages contamination of the other eye. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. Water or normal saline should be used for cleansing the eye of any discharge, and one cotton ball should be used for each stroke.

The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk? A. Increase in the movement of secretions in the respiratory tract. B. Increase in circulating fibrinolysin C. Predisposition to renal calculi D. Increased metabolic rate

C. Predisposition to renal calculi

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C. Pressure injury. The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 minutes and reposition the client after 1 hour

A nurse records a score of 3 for a newborn taken one minute after birth. What would be a priority intervention for this newborn? A. This is a normal APGAR score requiring no further interventions B. Provide respiratory support C. Provide immediate life saving support D. Report the APGAR sore to the primary care provider

C. Provide immediate life saving support

Three days after surgery, a patient continues to have moderate to severe incisional pain. Based on the gate control theory, what action should the nurse take? A. Administer the pain medications in smaller doses but more frequently B. Decrease external stimuli in the room during painful episodes C. Reposition the patient and gently massage the patient's back D. Advise the patient to try to sleep following administration of pain medication

C. Reposition the patient and gently massage the patients back

An older patient with an unsteady gait requests a tub bath. Which action would be most appropriate? A. Add Alpha-Keri oil to the water to prevent dry skin B. Allow the patient to lick the door to guarantee privacy C. Assist the patient in and out of the tub to prevent falling D. Keep the water temperature very warm because the patient chills easily

C. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha -Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43-46 degrees C. Older patients have an increased susceptibility to burns due to diminished sensitivity.

When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? A. On a PRN (as needed) basis B. Conservatively C. Around the clock (ATC) D. Intramuscularly

C. The PRN protocol is totally inadequate for patients experiencing chronic pain. ATC doses of analgesics are more effective, whereas conservative pain management for whatever reason may prove ineffective. Intramuscular administration is not practical on a long range basis for a patient with chronic pain

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? A. "I can expect to have more discomfort in the area where the cold is applied" B. "I should expect more drainage from the incision after the ice has been in place" C. "I should see less swelling and redness with the cold treatment" D. "My incision may bleed more when the ice is first applied"

C. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound and decreased bleeding

A nurse implements cutaneous stimulation for a patient as part of a strategy for pain relief. Which nursing action exemplifies in the use of this technique? A. The nurse plays soft music in the patient's room B. The nurse assists the patient to focus on something pleasant rather than on pain C. The nurse gives the patient a massage before bed D. The nurse teaches the patient deep breathing techniques for relaxation

C. The nurse gives a massage before bed

The nurse is caring for a Penrose drain for a patient post abdominal surgery. What nursing action reflects a step in care of a penrose drain that needs to be shortened each day? A. The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain B. The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain C. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion and cuts off the end of the drain with sterile scissors D. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain

C. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion and cuts off the end of the drain with sterile scissors

The nurse is changing the dressing of a patient with a gunshot wound. What nursing action would the nurse provide? A. The nurse uses wet to dry dressings continuously. B. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown C. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment D. The nurse packs the wound cavity tightly with dressing material

C. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment

Using proper body mechanics, which motions would the nurse make to move an object? A. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object B. The nurse uses the muscles of the back to help provide the power needed in strenuous activities C. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting or pulling D. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it to reduce the energy needed to lift the weight against the pull of gravity.

C. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting or pulling

A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? A. Drinking a cup of regular tea at night induces sleep B. Using alcohol moderately promotes a deep sleep C. Aging decreases the amount of REM sleep a person experiences D. Exercising decreases REM and NREM sleep

C. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increase both REM and NREM sleep

A nurse is caring for a 26 year old male patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A. Have the patient extend his arms outward and cross his legs on top of a pillow. B. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side C. Have the patient cross his arms on his chest and place a pillow between his knees D. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

C. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees. (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed towards the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is caring for a hospitalized 3 year old female who is having surgery for a cleft palate repair. While in the hospital, the parents of the child tell the nurse that their child who was previously potty trained has begun to wet her pants. What is the best response of the nurse? A. We should have a child psychologist assess your child B. Just put a diaper on her while she in in the hospital C. This is normal; children often regress during difficult periods or crises D. You should offer her a reward for not wetting the bed

C. This is normal; children often regress during difficult periods or crises

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do? A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve B. Cut the gown with scissors to allow arm movement. C. Thread the bag and tubing through the gown sleeve, keeping the line intact D. Temporarily disconnect the tubing from the IV container, threading it the other gown

C. Threading the bag and tubing through the gown sleeve keeps the system in tact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in the case of an emergency.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? A. Ineffective Coping: Multiple Stressors of New Job B. Sleep Deprivation: Difficulty Falling Asleep C. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern D. Risk for Injury: Activity Intolerance/Sleep Deprivation

C. When assessment data point to a sleep problem that is anemable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined

A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always take a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15min before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for a sleeping medication

C. When providing care, first use the least restrictive intervention. Of these options, allowing the client to follow their usual bedtime routine represents the lease change, so it is the first intervention to try.

A patient who recently underwent amputation of a leg complains of pain in the amputated part. What would the nurse's best response? A. Your pain cannot exist because the leg has been amputated B. Your pain is a phenomenon known as ghost pain C. Your pain is a real experience D. You are experiencing central pain syndrome

C. Your pain is a real experience

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions. Arrange from first to last. A. Notify the physician immediately of the situation B. Cover the exposed tissue with sterile towels moistened with sterile NSS C. Place the patient in the low Fowler's position

C.B.A. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowlers position, cover the exposed tissue with sterile towels and moistened with NSS., and notify the physician immediately of the situation

A nurse caring for adults in a physician's office notes that some patients age more rapidly than other patients of the same age. The nurse researches aging theories that attempt to describe how and why aging occurs. Which statements apply to the immunity theory of aging? (Select all that apply) A. Chemical reactions in the body produce damage to the DNA B. Free radicals have adverse effects on adjacent molecules. C. Decrease in the size and function of the thymus causes infections. D. There is much interest in the role of vitamin supplementation E. Lifespan depends on a great extent to genetic factors F. Organisms wear out from increased metabolic functioning

C.D. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infections. There is much interest in vitamin supplementations (such as Vitamin E) to improve immune function. In the cross linkage theory, cross linkage is a chemical reaction that produces damage to the DNA and cell death. The free radical theory states that free radicals, formed during cellular metabolism, are molecules with separated high energy electrons, which can have adverse effects on adjacent molecules.The genetic theory of aging holds that lifespan depends to a great extent on genetic factors. According to the wear and tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors

In which situations has the nurse used a dressing properly? Select all that apply. A. A nurse places a surgipad directly over an incision B. A nurse places a transparent dressings over an ABD to help keep the wound dry C. A nurse places OpSite over a central venous access device insertion site D. A nurse uses appropriate aseptic techniques when changing a dressing E. A nurse places Sof Wick around a drain insertion site F. A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing

C.D.E. A nurse places Opsite over a central venous access device insertion site. A nurse uses appropriate aseptic techniques when changing a dressing. A nurse places Sof Wick around an insertion site

A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D Orthostatic hypotension E. Nausea

C.D.E. Bradypnea, Orthostatic hypotension, Nausea

Nurses assess patients who have physiologic responses to pain. Which examples of pain response are physiologic responses? (select all that apply) A. Exaggerated weeping and restlessness B. Protecting the painful area C. Increased blood pressure D. Muscle tension and rigidity E. Nausea and vomiting F. Grimacing and moaning

C.D.E. Increased blood pressure. Muscle tension and rigidity. Nausea and vomiting

A nurse is screening for Alzheimer's disease (AD) in patients in a long term care facility. Which facts regarding AD are accurate? (Select all that apply) A. AD accounts for about one-third of the cases of dementia in the United States B. AD primarily affects young to middle adults C. Scientists estimate that more than 5 million people have AD. D. Nearly half of 85 year old adults have AD E. AD affects brain cells and is characterized by patchy areas of the brain that degenerate F. AD is a progressively serious but not a life threatening disease

C.D.E. Scientists estimate that more than 5 million people have AD. Nearly half of 85 year old adults have AD. AD affects brain cells and is characterized by patchy areas of the brain that degenerate

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? (select all that apply) A. Clean the wound with each dressing change using aggressive motions to remove necrotic tissue B. Use povidone-iodine or hydrogen peroxide to irrigate and clean the ulcer C. Use whirlpool treatments, if ordered, until the ulcer is considered clean D. Keep the ulcer tissue moist and the surrounding skin dry E. Use a dressing that absorbs exudate but maintains a moist healing environment F. Pack wound cavities densely with dressing material to promote tissue healing

C.D.E. Use whirlpool treatments, if ordered, until the ulcer is clean. Keep the ulcer tissue moist and the surrounding skin dry. Use a dressing that absorbs exudate but maintains a moist healing environment

Which exercises would the nurse recommend when planning isometric exercise for a patient? (Select all that apply) A. Jogging B. Range of motion exercises C. Contracting the quadriceps D. Kegel exercises E. Bicycling F. Contracting and releasing the gluteal muscles

C.D.F. Contracting quadriceps, Kegel exercises, Contracting and releasing the gluteal muscles

A school nurse is preparing a talk on safety issues for parents of school aged children to present at a parent teacher meeting. Which topics should the nurse include based on the age of the children? (Select all that apply) A. Child proofing the home B. Choosing a car seat C. Teaching pedestrian safety D. Providing swimming lessons and water safety rules E. Discussing alcohol and drug consumption related to motor vehicle safety F. Teaching children how to stop, drop, and roll

C.D.F. Important safety topics for school aged children include pedestrian traffic safety, water safety, and fire safety. Childproofing a home would be appropriate for parents of a toddler, choosing a carseat would be a more appropriate topic fo parents of an infant or toddler, and teaching drug and alcohol as it relates to motor vehicle safety would be more appropriate topic for parents of adolescents

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A. He is aware of his surroundings at this point B. He in in delta sleep at this time C. It would be most difficult to awaken him at this time D. This is most likely an NREM stage E. This stage constitutes around 20-25% of total sleep F. The muscles are relaxed in this stage

C.E. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20-25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

A nurse is caring for patients with alterations in mobility. Which nursing interventions are recommended for these patients? (Select all that apply) A. For increased cardiac workload, instruct the patient to lie in the prone position B. For ineffective breathing patterns, encourage shallow breathing and coughing C. For orthostatic hypotension, have the patient sleep sitting up or in an elevated position D. For impaired physical mobility, perform ROM exercises every 2 hours E. For constipation, increase fluid intake and roughage F. For impaired skin integrity, reposition the patient in the correct alignment at least every 1 to 2 hours

C.E.F. For orthostatic hypotension, have the patient sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the patient in the correct alignment at least every 1 to 2 hours

A nurse is assessing a 55 year old female patient. What is a normal physical change in the middle adult? (select all that apply) A. Skin moisture increases B. Hormone production increases C. Hearing acuity diminishes D. Cognitive ability diminishes E. Cardiac output decreases F. There is a loss of calcium from bones

C.E.F. Hearing acuity diminishes. Cardiac output decreases. There is a loss of calcium from bones

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

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

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound. Select all that apply. A. Enhanced healing due to the presence of sugars and proteins B. Delayed healing due to dead tissue present in the wound C. Decreased effectiveness of antibiotics against the bacteria D. Impaired skin integrity due to overhydration of the cells of the wound E. Delayed healing due to cells dehydrating and dying F. Decreased effectiveness of the patient's normal immune process

C.F. Wound biofilms are the result of wound bacteria growing in clumps, imbedded in thick, self made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient. Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Dessication is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse is ambulating a 48 year old female patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient. A. Grasp the gait belt B. Stay with the patient and call for help C. Place feet wide apart with one foot in front D. Gently slide patient down to the floor protecting her head E. Pull the weight of the patient backward against your body F. Rock your pelvis out on the side of the patient

C.F.A.E.D.B. Place feet wide apart with one foot in front. Rock your pelvis out on the side of the patient. Grasp the gait belt. Pull the weight of the patient backward against your body. Gently slide patient down to the floor protecting her head. Stay with the patient and call for help.

A nurse is teaching a parenting class for parents with infants. What is an example of an appropriate teaching point for this developmental age? A. Place the infant on the side or stomach when sleeping B. Line the crib with bumpers to keep the infant from hitting the posts C. If choking occurs, give back blows and chest thrusts or CPR D. Wean the infant from the breast or bottle when 9 months old

C.If choking occurs, give back blows and chest thrusts or CPR

Type of wounds: Contusion

Cause: Blunt instrument or overlying skin remains in tact, with injury to underlying soft tissue; Possible resultant bruising and/or hematoma

Types of wounds: Puncture

Cause: Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

Types of wounds: Pressure Ulcer

Cause: Compromised circulation secondary to pressure or pressure combined with friction

Type of Wounds: Abrasion

Cause: Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

Types of wounds: Thermal

Cause: High of ow temperatures; cellular necrosis as a possible result

Types of wounds: Venous ulcers

Cause: Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

Types of Wounds: Diabetic Ulcers

Cause: Injury and underlying diabetic neuropathy, peripheral artery disease, diabetic foot structure.

Types of wounds: Arterial ulcer

Cause: Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

Type of wounds: Laceration

Cause: Tearing of skin, and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue.

Types of wounds: Chemical

Cause: Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Types of wounds: Irradiation

Cause: Ultraviolet light or radiation exposure

Type of wounds: Penetrating

Causes: Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

Types of wounds: Avulsion

Causes: Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Concept Mastery Alert-32

Caution is necessary when performing range of motion exercises with patient's who are unresponsive because these patients are unable to report complaints of pain

Guidelines for Nursing care Cleaning wounds

Cleaning Wounds with unapproximated edges -Use standard precautions; transmission based if indicated -Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution -Use a new swab or gauze for each circle -Clean the wound in full or half circles beginning in the center and working toward the outside -Clean at leas 1 inch beyond the end of the new dressing -If a dressing not being applied, clean to at least two inches beyond the wound margins

Guidelines for nursing care Cleaning wounds

Cleaning wounds with approximate edges: -Use standard precautions; transmission based when indicated -Moisten a sterile gauze pad or swab with the prescribed cleansing agent. -Use a new swab or gauze for each downward stroke -Clean from top to bottom -Work outward from the incision in lines parallel to it -Wipe from the clean area toward the less clean area

protective supine position

Complication to be prevented and suggested preventive actions *Exaggerated curvature of the spine and flexion of the hips- provide a firm, supportive mattress; use a bed board if necessary *flexion contracture of the neck- place pillows under the upper shoulders, neck, and head so that the head and neck are held in the correct position *internal rotation of the shoulders and extension of the elbows(hunch shoulders)- place pillows or arm supports under the forearms so that the upper arms are alongside the body and the forearms are pronates slightly *flexion of the lumbar curvature- place rolled towel or small pillow under lumbar curvature if needed *extension of the fingers and abduction of the thumbs (claw hand deformities)- use hand-wrist splints if appropriate *external rotation of the femurs- place sandbags or a trochanter roll alongside the hips and the upper half of the thighs *hyperextension of the knees- place a pillow under the lower legs from below the knees to the ankles *footdrop- use a footdrop or make an improvised firm foot support to hold the feet in dorsal flexion; high top sneakers may also be recommended

Protective Prone Position

Complication to be prevented and suggested preventive actions *flexion on the cervical spine- place a small pillow under the head *hyperextension of the spine; impaired respirations- place some suitable support under the patient between the end of the rib cage and the upper abdomen if this facilitates breathing and space is available *footdrop- move the patient down in bed so that the feet are over the mattress, or support the lower legs on a pillow just high enough to keep the toes from touching the bed

protective side lying or lateral position

Complication to be prevented and suggested preventive actions *lateral flexion of the neck- place a pillow under the head and the neck *inward rotation of the arm and interference with respiration- place a pillow under the upper arm; lower arm should be flexed and positioned comfortably * extension of the finger and abduction of the thumbs- provide hand wrist splint if necessary *internal rotation and adduction of the femur- use one or two pillows as needed to support the leg from the groin to the foot *twisting of the spine- ensure that both shoulders are aligned with both hips

protective sims position

Complication to be prevented and suggested preventive actions *lateral flexion of the neck-place a small pillow under the head unless the drainage of oral secretions is desired *damage to nerves and blood vessels in the axillae of the lower arm- carefully position lower arm behind and away from the patients back *internal shoulder rotation and adduction- abduct the upper shoulder slightly so that the shoulder and elbow are flexed; place a pillow between the chest and upper arm *internal rotation and adduction of the hip; lumbar lordosis- place a pillow under the upper flexed leg from the groin to the foot *twisting the spine- ensure that both shoulders are aligned with both hips *footdrop- support the lower foot in dorsiflexion with a sandbag

Fowler's position

Complication to be prevented and suggested preventive actions *Flexion contracture of the neck- allow the head to rest against the mattress or be supported by a small pillow only *Exaggerated curvature of the spine- use a firm support for the back; position the patient so that angle of elevation starts at the hips *Dislocation of the shoulder- support the forearms on pillows to elevate them sufficiently so that no pull is exerted on the shoulder *Flexion contracture of the wrist- support the hand on pillows so that is in natural alignment with the forearm *Edema of the hand- support the hand so that it is slightly elevated in relation to the elbow *Flexion contractures of the fingers and abduction of the thumbs- provide hand wrist splints if necessary *Impaired lower extremity circulation and knee contracture, pressure on heels-elevate the knees for only brief periods; place one or two pillows under the lower legs from below the knees to the ankles; avoid pressure on the popliteal vessels, avoid using the knee gatch. *External rotation of the hips- use trochanter role *Foot drop- support the feet in dorsal flexion. Use footboard; high top sneakers can also be used

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain B. A client who has incisional pain 72 hours following a pacemaker insertion C. A client who has food poisoning and reports abdominal cramping D. A client who has episodic back pain following a fall 2 years ago

D. A client who has episodic back pain following a fall two years ago

The nurse is performing pressure ulcer assessment for patients in a hospital setting . Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer? A. a newborn B. A patient with cardiovascular disease C. An older patient with arthritis D. A critical care patient

D. A critical care patient

A nurse administers pain medication to patients on a med surg ward. Which patient would benefit from a PRN drug regimen as an effective method of pain control? A. A patient experiencing acute pain B. A patient in the early postoperative period C. A patient experiencing chronic pain D. A patient in the postoperative stage with occasional pain

D. A patient in the postoperative stage with occasional pain

Which of the following means of pain control is based on the gate control theory? A. Biofeedback B. Distraction C. Hypnosis D. Acupuncture

D. Acupuncture

Following assessment of of an obese adolescent, a nurse considers nursing diagnoses for the patient. Which diagnosis would be most appropriate? A. Risk for injury B. Risk for delayed development C. Social Isolation D. Disturbed body image

D. Adolescents who are obese are at a high risk for a disturbed body image. Risk for injury would be appropriate for a risk taker, a risk factor for delayed development may be ADHD, and social isolation may occur with low self esteem

A patient who is in pain strikes out at a nurse who is attempting to perform a bed bath. This patient is displaying what pain response? A. Involuntary B. Behavioral C. Physiologic D. Affective

D. Affective

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have outlived their usefulness. What is the term for this type of prejudice? A. Harassment B. Whistle blowing C. Racism D. Ageism

D. Ageism is a from of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant person takes advantage of or overpowers a less dominant person (may involve sexual harassment or power struggles). Whistle blowing involves reporting illegal or unethical behavior in the workplace. Racism is prejudice against other races and ethnic groups

The nurse should obtain a sleep history on which patient as a protocol? A. Only patient's who have been suffering from a sleep disorder B. Only patient's who suffer from a sleep disorder or have been unconscious C. Patient's who suffer from a sleep disorder or who are spending time in the CCU D. All patients admitted to a health care agency

D. All paitents who are admitted to a health care agency

A nurse caring for the skin of patients of different age groups should consider which accurately described condition? A. An infant's skin and mucous membranes are protected from infection by a natural immunity B. Secretions form skin glands are at their maximum from age 3 on. C. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness D. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions

D. An adolescent's skin ordinarily has enlarged sebaceous glands and increasing glandular secretions

A nurse is caring for a client who is sitting in a chair and asks to return to the bed. Which of the following actions is the nurses priority at this time. A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist with the transfer C. Use a transfer belt and assist the client back into bed D. Determine the clients ability to help with the transfer

D. Determine the clients ability to help with the transfer. The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the clients ability to help with transfers and then proceed with a safe transfer

What interview question would be the best choice for the nurse to use to assess for recent changes in a patient's sleep-wakefulness pattern? A. In what way does the sleep you get each day affect your every day living? B. How much sleep do you think you need to feel rested? C. What do you usually do to help yourself fall asleep? D. Do you usually go to bed and wake up about the same time each day?

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

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. I spent my whole life dreaming about retirement, and now I wish I had my job back B. It's been so stressful for me to have to depend on my son to help around the house C. I just heard my friend Al died. That's the third one in 3 months D. I keep forgetting which medications I have taken during the day

D. I keep forgetting which medications I have taken during the day

The nurse observes a hospitalized 15 year old male refuse to eat his meal tray and state: I usually eat pizza at home. I can't eat the food in here. This type of rebellious behavior is characteristic of which of Erik Erickson's stages of psychosocial development? A. Autonomy vs. shame and doubt B. Initiative vs guilt C. Industry vs inferiority D. Identity vs role confusion

D. Identity vs role confusion

A patient will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this patient? A. Patients who are fearful of walking should be told to look at their feet when walking to ensure correct positioning B. Patient who can lift their legs only 1 to 2 inches off the bed do not have sufficient muscle power to permit walking C. Nurses should never assist patients with ambulation without a physical therapist present D. If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patients head.

D. If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patient's head

During range of motion exercises, the nurse turns the sole of a patient's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions? A. Internal and external rotation of the ankle B. Dorsiflexion and plantar flexion of the ankle C. Flexion and extension of the ankle D. Inversion and eversion of the ankle

D. Inversion and eversion of the ankle

Which of the following nursing diagnoses would be appropriate for many middle adults? A. Risk for Imbalanced nutrition: Less than body requirements B. Delayed Growth and Development C. Self care deficit D. Caregiver Role Strain

D. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24 hours care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? A. "It's not a good idea to ask for pain medication regularly as it can be addictive." B. "It is better to wait until the pain gets unbearable before asking for pain medication." C. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." D. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

D. Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time

The nurse is implementing nursing interventions to promote sleep on a busy hospital ward. Which intervention is the best choice for these patients? A. Encourage the patients to take a shower prior to bedtime B. Have the patient's set an alarm clock so they are not worried about getting up C. Create a warm, dark environment in the patient's room D. Offer patients a small carbohydrate and protein snack before bedtime

D. Offer patients a small carbohydrate and protein snack before bedtime

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? A Using sterile dressing supplies B. Suggesting dietary supplements C Applying antibiotic ointment D. Performing careful hand hygiene

D. Performing careful hand hygiene. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important

A nurse observes a marked inflammation of the gums, along with recession and bleeding of the gums, and documents this observation using which term? A. Glossitis B. Caries C. Cheliosis D. Periodontitis

D. Periodontitis is a marked inflammation of the gums, whereas caries refers to the presence of tooth decay. Cheilosis is ulceration of the lips, and glossitis is an inflammation of the tongue

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? A. Transient pain B. Superficial pain C. Phantom pain D. Referred pain

D. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically

The nurse is visiting a patient at home who is recovering from a bowel resection. The patient complains of constant pain and discomfort and displays signs of depression. When assessing this patient for pain, what should be the nurse's focal point? A. Judging whether the patient is in pain or is just depressed B.Beginning pain medications before before the pain is too severe. C. Administering a placebo and performing a reassessment of pain D. Reviewing and revising the pain management treatment

D. Reviewing and revising the pain management treatment

A nurse working the night shift in a pediatric unit observes a 10 year old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect A. Bruxism B. Cataplexy C. Restless leg syndrome D.Somnambulism

D. Somnambulism (sleep walking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding ones teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs

Based on an understanding of the cognitive changes that occur normally with aging, what might the nurse expect a newly hospitalized older adult to do? A. Talk rapidly but be confused B. Withdraw from strangers C. Interrupt with frequent questions D. Take loger to respond and react

D. Take longer to respond and react

A nurse assesses a patient's alignment and documents which data as a normal finding? A. The chest is held upward and backward B. The abdominal muscles are held downward and the buttocks upward C. The knees are slightly bent D. The base of support is on the soles of the feet

D. The base of support is on the soles of the feet

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates his behavior after a social interaction B. The client states he is learning to trust others C. The client wishes to find meaningful friendships D. The client expresses concerns about the next generation

D. The client expresses concern about the next generation

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows the mortician usually washes the body. Which response would be most appropriate? A. Inform the family that there is no need for them to wash the body since the mortician typically does this B. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel C. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens D. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help

D. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

An unresponsive patient is wearing gas permeable contact lenses. How would the nurse remove these lenses? A. Gently irrigate the eye with an irrigating solution from the inner canthus outward B. Grasp the lens with a gentle pinching motion C. Don sterile gloves before attempting the removal procedure D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release it

D. The lens must be situated on the cornea, not the sclera, before removal. To remove hard contacts, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean, not sterile, gloves are used

When assessing the health of a neonate, the nurse should be aware that: A. The neonate has not yet developed reflexes that allow sucking, swallowing, or blinking B. The neonate has labile temperature control that responds slowly to environmental temperatures C. The neonate is alert to the environment but cannot distinguish color and form D. The neonate hears and turns toward sound and can smell and taste

D. The neonate hears and turns toward sound and can smell and taste

The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly? A. The nurse uses a safety pin to attach the pad to the bedding B. The nurse covers the heating pad with a heavy blanket C. The nurse places the heating pad under the patient's neck D. The nurse keeps the pad in place for 20 to 30 minutes, Assessing it regularly

D. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly

A nurse is assisting a patient from a bed to a wheelchair. Which nursing action is appropriate? A. The nurse discourages the patient from helping with the transfer B. The nurse administers pain medication following the transfer C. The nurse grabs and holds the patient by his arms D. The nurse uses assistive devices when lifting more than 35 pounds of patient weight.

D. The nurse uses assistive devices when lifting more than 35 pounds of patient weight

The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform? A. The nurse places a foam wedge under his body to keep body weight off the patient's back. B. The nurse uses a ring cushion to protect reddened areas from additional pressure C. The nurse increases the amount of time the head of the bed is elevated D. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair

D. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair

A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position? A. Side-lying. B. Fowler's. C. Sims'. D. Prone.

D. The prone position is contraindicated in patient's who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis, or forward curvature of the lumbar spine

A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? A. Keeping the head of the bed elevated as often as possible B. Massaging over bony prominences C. Repositioning bed bound patients every 4 hours D. Using a mild cleansing agent when cleansing the skin

D. To prevent pressure ulcers, the nurse should cleanse the skin routinely an whenever any soiling occurs by using a milk cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed bound patients should be repositioned every 2 hours

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: A. Pruritis B. Urinary retention C. Vomiting D. Respiratory depression

D. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritis, urinary retention, and vomiting may occur but are not life threatening

When giving a back rub to an older patient at home, the nurse notices a stage II pressure ulcer. What nursing interventions would the nurse perform next? A. Place a sterile dressing over the pressure ulcer B Use a wet to dry dressing on the pressure ulcer C. Use a nonadherent dressing and changes it every 3 hours D. Use normal saline to clean the pressure ulcer

D. Use normal saline to clean the pressure ulcer

A nurse is preparing the environment in a hospital room for a newly admitted patient. Which actions are recommended? (Select all that apply) A. Do not store patient's personal items in the bedside stand because nurses need to open and close the stand to obtain bath basin, lotion, and other items. B. Position patients bed at the appropriate height with the wheels unlocked. C. Follow the principles of surgical asepsis at the bedside D. Do not place soiled dressings or anything with a strong odor in the waste receptacle in the patient's room E. In general, keep the room temperature between 20 and 23 (68 and 74) F. Avoid carrying out conversations immediately outside the patient's room

D.E.F. Do not place soiled dressings or anything with a strong odor in the waste receptacle in the patient's room. In general, keep the room temperature between 20 and 23 (68 and 74). Avoid carrying out conversations immediately outside the patient's room

A nurse working the night shift at the hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply A. REM sleep constitutes much of the sleep cycle of a preschool child B. By the age of 8 years, most children no longer take naps C. Sleep needs usually decrease when physical growth peaks D. Many adolescents do not get enough sleep E. Total sleep decreases in adults with a decrease in stage IV sleep F. Sleep is less sound in older adults and stage IV sleep may be absent

D.E.F. Many adolescents do not get enough sleep due to the stresses of school, activities, and part time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks

gastrointestinal system

Effects of exercise: Increased appetite Increased intestinal tone Effects of immobility: Disturbance in appetite Altered protein metabolism Altered digestion and utilization of nutrients Decreased peristalsis

urinary system

Effects of exercise: Increased blood flow to kidneys Efficiency in maintaining fluid and acid-base balance Efficiency in excreting body wastes Effects of immobility: Increased urinary stasis Increased risk for renal calculi Decreased bladder muscle tone

Respiratory system

Effects of exercise: Increased depth of respiration Increased respiratory rate Increased gas exchange at alveolar level Increased rate of carbon dioxide excretion Effects of immobility: Decreased depth of respirations Decreased rate of respiration Pooling of secretions Impaired gas exchange

Metabolic system

Effects of exercise: Increased efficiency of metabolic system Increased efficiency of body temperature regulation Effects of immobility: Increased risk for electrolyte imbalance Altered exchange of nutrients and gases

cardiovascular system

Effects of exercise: Increases efficiency of the heart Decreases resting heart rate and blood pressure Increases blood flow and oxygenation Effects of immobility: Increased cardiac workload Increased risk for orthostatic hypotension Increased risk for venous thrombosis

Physiological well being

Effects of exercise: Energy, vitality, general well being Improved sleep Improved appearance Improved self concept Positive health behaviors Effects of immobility: Increased sense of powerlessness Decreased self concept Decreased social interaction Decreased sensory stimulation Altered sleep wake pattern Increased risk for depression Risk for learned helplessness

integument

Effects of exercise: Improved tone, color, and turgor, resulting from improved circulation Effects of immobility: Increased risk for skin breakdown and formation of pressure ulcers

Musculoskeletal system

Effects of exercise: Increased muscle efficiency Increased coordination Increased efficiency of nerve impulse transmission Effects of immobility: Decreased muscle size, tone, strength Decreased joint mobility Bone demineralization Decreased endurance and stability Increased risk for contracture formation

What is eschar? And when should it never be removed?

Eschar is a thick, leathery scab or dry crust that is necrotic (dead tissue) and must be removed before the stage can be determined accurately. However, stable (dry, adherent, intact, without erythema of fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed

Plantar flexion

Flexion of the foot. (Example: a persons foot is in plantar flexion in the footdrop position)

Concept Mastery Alert-30

For the patient who is incontinent, it is important to keep the area clean and dry. Do not use soap, and protect the area with moisture barriers.

Abduction

Movement away from the midline of the body. (An example is A persons arm is abducted when it is moved away from the body)

Adduction

Movement toward the midline of the body. (Example: a persons arm is adducted when it is moved away from an outstretched position to a position alongside the body)

Endurance

Normal finding: Ability to turn in bed, maintain correct alignment when sitting and standing, ambulate, and perform self care activities Significant alterations: Physiologic or psychological inability to tolerate an increase in activity: Significantly increased pulse, respiration, blood pressure after rest Shortness of breath, dyspnea Weakness Pallor Confusion Vertigo Pain

Joint structure and function

Normal finding: Absence of joint deformity Full range of motion Significant alterations: Limitation in the normal range of motion Increased joint mobility Swelling or tenderness in or around the joint Heat or redness Crepitation Deformities Muscle atrophy, nodules, skin changes Asymmetry of involvement

muscle mass, tone, and strength

Normal finding: Adequate muscle mass, tone, and strength to accomplish movement and work Significant alterations: Atrophy, hypertrophy Hypotonicity (flaccidity), spasticity Paresis or paralysis

General ease of movement

Normal finding: Body movements are: Voluntarily controlled (purposeful) Fluid Coordinated Significant alterations: Tremors Tics Chorea Athetosis Dystopia Fasciculations Myoclonus Oral facial dyskinesias

Gait and posture

Normal finding: Head erect, vertebrae are straight Knees and feet point forward Arms at side with elbows flexed Arms swing freely in alternation with swings While one leg is in the stance phase, the other is in the swing phase Significant alterations: Abnormalities of gait and posture Spastic hemiparesis Scissors gait Steppage gait Sensory ataxia Cerebellar ataxia Parkinsonian gait Gait of old age Use of assistive devices for ambulation

Alignment

Normal finding: Independent maintenance of correct alignment: In the standing and sitting position, a straight line can be drawn from the ear through the shoulder and hip In bed, the head, shoulders, and hips are aligned Significant alterations: Abnormal spinal curvatures Inability to maintain correct alignment independently

Focus on the older adult: Nursing strategies to address age related changes in skin Age related changes: Melanocytes (cells that make pigment that colors hair and skin) decline in number -Hair becomes gray-white -Skin may be unevenly pigmented

Nursing strategies - Assist patient with skin checks, observing for any signs of melanoma or other skin abnormalities

Focus on the older adult: Nursing strategies to address age related changes in skin Age related changes: Activity of the sebaceous and sweat glands decreases: -Skin becomes drier -Pruritis (itching may occur)

Nursing strategies: - Clean perineal area daily but do not bathe full body on a daily basis - Apply lotions as needed - Encourage adequate hydration

Focus on the older adult: Nursing strategies to address age related changes in skin Age related changes: Subcutaneous and dermal tissue become thin: - Skin is more easily injured -Skin has less capacity to insulate -Skin wrinkles more easily -Sensation of pressure and pain is reduced

Nursing strategies: - Do not apply tape to skin unless necessary - Check skin frequently to observe for any signs of a pressure ulcer - Pad bony prominences if necessary - Assess pressure tolerance by checking pressure points for redness after 30 minutes

Focus on the older adult: Nursing strategies to address age related changes in skin Age related changes: Collagen fiber is less organized: - Skin loses elasticity

Nursing strategies: - Check skin frequently for tears, irritation, or breakdown

Focus on the older adult: Nursing strategies to address age related changes in skin Age related changes: Cell Renewal is shorter: - Healing time is delayed

Nursing strategies: -Perform careful skin assessments , looking for signs of skin breakdown

Nursing strategies to address age related changes in hygiene: Age related changes: Impaired oral Mucous Membrane: Loss of elasticity; atrophy of epithelial cells, diminished blood supply to connective tissue Decreased salivation Use of medications for chronic conditions that may cause dry mouth

Nursing strategies: Floss and brush teeth with fluoride toothpaste twice a day; rinse after meals Brush dentures twice a day and rinse with cool water; remove and rinse dentures and mouth after meals Avoid mouthwashes with alcohol content Inspect mouth daily for lesions and inflammation Use lubricant on lips Suck on sugar free candies, chew sugarless gum, use salivary substitutes Continue with dental exams at the dentist every 6 months

Nursing strategies to address age related changes in hygiene: Age related changes: Impaired physical mobility: Decreased range of motion Presence of chronic conditions that compromise functional ability Decreases muscle strength and agility

Nursing strategies: Use adaptive devices for hygiene such as a toothbrush with a large handle or extended handle, long handled body sponge, shower chair, grab bars Provide for safety in the bathroom. Use nonslip mats, grab bars

Nursing strategies to address age related changes in hygiene: Age related changes: Risk for Impaired skin integrity Diminished secretion of natural oils and perspiration Loss of elasticity Thinning of epidermis, loss of elastin and subcutaneous fat

Nursing strategies: Use safe water temperatures to bathe, warm water not hot Avoid soap, used PH balanced skin cleansers Shower instead of tub bath Use skin moisturizers and emollients at least daily Bath regularly, but less often (not every day)

external rotation

Rotation of a joint away from the middle of the body. (Example: a leg is rotated externally when it turns outward at the hip and the toes point away from the midline of the body)

internal rotation

Rotation of a joint toward the middle of the body. (Example: a leg is rotated internally when it turns inward at the hip and toes point toward the midline of the body

opposition

Rotation of the thumb around its long access (movement of the thumb across the palm to touch each fingertip of the same hand).

Guidelines for nursing care Measuring wounds and pressure ulcers

Size of the wound - Draw the shape and describe it -Measure the length, width, and diameter (if circular) Depth of the wound -Perform hand hygiene; put on gloves -Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down -Mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wounds margin -Remove the swab and measure the depth with a ruler Wound tunneling - Use standard precautions; use appropriate transmission based precautions when indicated -Perform hand hygiene and put on gloves -Determine direction: Moisten a sterile, flexible applicator with saline and gently insert a sterile applicator into the site where tunneling occurs. View the direction of the applicator as if it were the hand of a clock. The direction of a patient's head represents 12 o clock. Moving in a clockwise direction, document the deepest sites where the wound tunnels - Determining the depth: While the applicator is inserted into the tunneling, mark the point on the swab that is even with the wound's edge, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Remove the swab and measure the depth with a ruler. -Document the direction and depth of tunneling

ATI- Active learning scenario 55 List the six pressure injury stages along with a brief description of the assessment finding typical for ulcers at each stage

Suspected deep tissue injury, depth unknown: Discoloration but intact skin from damage to underlying tissue. Stage I, nonblanchable erythema: intact skin with an area of persistent nonblanchable redness, typically over a bony prominence, that can feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer's coloring differs from that of the surrounding area Stage II, partial thickness,: Involves the epidermis and dermis. The ulcer is visible with reddish-pinkish bed without slough or bruising, superficial and can appear as an abrasion, blister, or shallow crater. Edema persists. The ulcer can become infected, possibly with pain and scant drainage Stage III, full thickness skin loss: Damage to or necrosis of subcutaneous tissue. The ulcer can extend down to, but not through, underlying fascia. The ulcer appears as a deep craterwith or without undermining or tunneling of adjacent tissue and without exposed muscle or bone. Drainage and infection are common Stage IV, full thickness tissue loss: Destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab like material), or slough (tan, yellow, or green scab like material) Unstageable/Unclassified, full thickness skin or tissue loss, depth unknown: No determination of stage because eschar or slough obscures the wound bed. The actual depth of injury is unknown

Pronation

The assumption of the prone position. (Example: a person is in the prone position when lying on the abdomen; a persons palm is prone when the forearm is turned so that the palm faces downward)

Suppination

The assumption of the supine position. (Example: a person is in the supine position when lying on the back; a persons palm is in the supine position when the forearm is turned so that the palm faces upward)

What does blanching mean?

The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin. over the area under pressure. This makes the skin appear paler in areas where circulation is adequate

Active assist exercise

The nurse may provide some minimal support.- improves joint mobility and increases circulation to the affected part

Active exercises

The patient independently moves joints through their full range of motion- isotonic exercises Improves joint mobility and increases circulation to the affected part. Also increases muscle mass, tone strength and improves cardiac and respiratory function

passive exercise

The patient is unable to move independently, and the nurse moves each joint through its range of motion. Improves joint mobility and increases circulation to the affected part

Flexion

The state of being bent. (Example: a persons cervical spine is extended when the head is bent forward, chin to chest)

Extension

The state of being in a straight line. (Example: a persons cervical spine is extended when the head is held straight on the spinal column)

Hyperextension

The state of exaggerated extension- often in an angle greater than 180 degrees. (Example: a persons cervical spine is hyperextended when looking overhead toward the ceiling)

Skin care problems (Definitions and treatments) Acne Definition: A skin condition that is characterized by clogged pores (blackheads, whiteheads, pimples), caused by dead skin cells and sebum (oil) sticking together in the pore. Sometimes bacteria that live on the skin also get inside the clogged pore. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large amount of bacteria inside, the pore becomes inflamed (red and swollen). If the inflammation foes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms and buttocks.

Treatment: -Avoid squeezing or picking infected areas because this can spread the infection and cause scarring. -Gently wash the face twice a ay with a mild cleanser and warm (not hot) water. -Use oil-free, water based moisturizers and makeup. look for products that are "noncomedogenic" or "nonacnegenic" Use cosmetics sparingly to avoid further blockage of the sebaceous ducts -Keep hair off the face and wash hair daily -Some acne treatments (both over the counter and prescription) can increase the skin's sensitivity to sunlight and ultraviolet light. Avoid sun/tanning booth exposure; use sunscreen -Patients with a lot of acne, cysts, or nodules should consider consulting a dermatologist

Skin care problems (definitions and treatments) Skin rashes: Definition: eruptions or inflammations of the skin that may be found anywhere on the body. May be precipitated by skin contact with an allergen, overexposure to the sun, and/or systemic causes, like a reaction to a medication

Treatment: -Wash area thoroughly with a mild cleansing agent and rinse well -Use a moisturizing lotion an a dry rash to prevent itching and promote healing -Use a drying agent on a wet rash -Try tepid baths to help relieve inflammation and itching -Use antiseptic sprays or lotions to help lessen itching, promote healing, and prevent skin breakdown -Avoid exposure to causative agent, if known - See a health care provider if symptoms do not respond to treatment or become worse

Skin Care Problems (definition and treatment) Dry Skin Definition: The skin loses moisture and may crack and peel, or become irritated and inflamed. Symptoms include scaling, flaking, itching and cracks in the skin.

Treatment: -Keep baths or showers short, and/or bathe less frequently. -Use warm, not hot water to bathe -Use as little soap as possible. Try mild cleansers or soaps. -Dry skin thoroughly and gently -Use moisturizers at least daily -Drink plenty of water throughout the day -Use a humidifier if the air is dry

Circumduction

Turning in a circular motion- this combines abduction, adduction, extension and flexion. (Example: circling the arm at the shoulder, as in bowling or tennis)

Rotation

Turning on an axis; the turning of a body part on the axis provided by its joint. (Example: a thumb is rotated when it is moved to make a circle)

paralysis

absence of strength secondary to nervous impairment

Types of wounds: incision

cause: cutting or sharp instrument; wound edges in close approximation and aligned

Ankylosis

consolidation and immobilization of a joint

Atrophy

decreased muscle size due to disease or neurological impairment

Flaccidity

decreased muscle tone; synonym for hypotonicity

Paresis

impaired muscle strength or weakness

hypertrophy

increase in muscle size (through exercise or training)

Footdrop (def)

is a contracture deformity in which the foot hangs in a plantar flexed position. This deformity prevents the heal from being placed on the ground and preventing walking

Range of motion

maximum degree of movement of which a joint is normally capable

Inversion

movement of the sole of the foot inward

Eversion

movement of the sole of the foot outward

Isokinetic

muscle contraction with resistance provided at a constant rate by external device Example- Rehab exercises for knee and elbow injury (lifting weights)

Isometric

muscle contraction without shortening Example: Contractions of quadriceps and gluteal muscles (yog)

Isotonic

muscle shorting and active movement Activities of Daily Living include Independent range of motion (Walking, swimming) Passive range of motion is not as beneficial as Active

Partial care

patient receive morning hygiene care at the bedside or seated near the sink in the bathroom; usually requires assistance with body areas that are difficult to reach (back)

Complete care

patients require assistance with all aspects of personal hygiene

self-care

patients who are capable of managing their own personal hygiene independently once oriented to the bathroom (offer back massage and assess day to day needs)

crepitation

the grating sound heard when the ends of a broken bone move together (bone on bone)