Wk 13 fundamentals

40. A nurse is obtaining a health history from a newly admitted patient. Which patient statement about alcohol intake is based on a common physiological response?

"After I go drinking, I have to urinate during the night."

84. An older adult client tells the nurse. "I don't bother exercising because I get too tired very quickly." What is the appropriate nursing response?

"Alternate periods of activity with periods of rest."

1. The nurse is teaching a client about ambulatory electrocardiogram Which client statement requires further nursing teaching? (Select all that apply.)

"🔅It is acceptable for me to go through the metal detector at the airport." 🔅This will help me understand how my heart performs when I swim."

77. A nurse administers a back rub to a patient after fi rst providing for privacy and maintaining standard precautions. Place the following steps in the order in which they should be implemented. 1. Apply warmed lotion to your hands. 2. Position the patient in the side-lying position. 3. Assess the skin for color, turgor, and skin breakdown. 4. Arrange the gown and top linens so that the patient's back is exposed. 5. Use variety of strokes to massage the muscles of the back and sacral area.

2, 4, 3, 1. 5

17. A nurse is calculating the maximum heart rate of a 20-yoar-old client who has undergone a prescribed fitness level test What should this elient's heart rate be?

200 beats per minute

50. During which time frame do people tarid to be the sleepiest?

2am and 4 a.m.

54. An adult client and the nurse have collaboratively calculated the client's maximum heart rate for the client's age The client has no major health problems but has very minimal experience with performing fitness exercise The client's target heart rate during exercise should be no more than what approximate percentage of the maximum heart rate?

50%

71. A nurse suspects that an older adult's insomnia may be partially attributable to excessive daytime napping. The nurse has taught the client that the client may not need as much sleep as the client believes. The nurse should know that older adults typically require how much sleep in any given 24-hour period?

7 to 9 hours

5. A patient is diagnosed with chronic fatigue syndrome. Which is most important for the nurse to eplore in relation to the patient's status?

Ability to provide self-care

16. A client diagnosed with impaired thermoregulation reports feeling uncomfortable due to excessive sweating. Which activity would help the nurse maintain the humidity of the environment?

Air conditioning the room

99. A nurse needs to administer the prescribed fitness test of a client who has had prior cardiac-related symptoms. Which of the followng fitness test methods is most suitable for the client?

Ambulatory electrocardiogram

86 A client is wearing a Holter montor in order to undergo a prescribed ambulatory electrocardigram. Which precaution should the client take during an ambulatory electrocardiography test?

Avoid a shower swim.

49. A nurse is caring for a client who has started phototherapy for seasonal affective disorder. Which instruction should the nurse give the client to prevent the recurrence of symptoms?

Avoid abrupt discontinuation of the therapy

94. A nurse is caring for a client diagnosed with sleep apnea. What should the nurse do in order to promote sleep in the client?

Avoid sedatives for sleeping.

61 A nurse is caring for a client who is nperiencing niusea and vomiting. Which nursing interventions should the nurse implemant to modify the clients environment to relieve nausea and vomiting?

Avoid strong odors in the client's room

83. A nurse is caring for a client who complains about sleep apnea. Which delivery device should the nurse use to administer oxygen to this client?

CPAP mask

96. A nurse is caring for client at a health care facility whose treatment includes exercises. Which nursing diagnosis is most likely for this client

Delayed Surgical Recovery

18. Which is the appropriate outcome for an adult pt. who has disturbed sleep because of nocturia?

Demonstrate a reduction in nighttime bathroom visits.

24. A patient tels the nurse that he experiences daylime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask?

Do you also have any recent lifestyle or behavior changes?

27. A nurse is caring for an elderly client at a health care facility. What should the nurse do to provide an appropriate environment for the client?

Ensure that the environment is warmer than normal.

A female client has been admitted tonthe hospital with a Dx of pnuemonia and admitted to a 4brm rm. the client has found it difficult to sleep in this enviroment and explained this to the nurse. The nurse first action should be what to the clinets complaint?

Facilitate as many aspects of the clients sleep ritual as possible

92. The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self-reporting tool is best for the nurse to utilize?

Fatigue Severity Scale (FSS)

30. Which concept associated with sleep should the nurse consider to plan nursing care for a hospitalized patient?

Fear can contribute to the need to stay awake.

60. A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic que stion the nurse can ask about the quality of the patient's sleep?

How would you describe your sleep?

93. Which patient statement indicates that the patient is experiencing bruxism?

I am told by my wife that I make a lot of noise grinding my teeth when I sleep.

79. The nurse is counseling a woman who is caring for her 83-year-old father. The father has had mental changes and is becoming more confused. The father lives with the daughter in her home. The nurse knows the daughter understands the father's care needs when she states which of the following?

I can send dad to the adult daycare; that way I can work and care for him at night"

57. A mother tells the nurse she is concerned because her 8 month old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response?

I recomend that you notify the childs pediatrician

41. A mother tells the nurse she is concerned because her 8 month old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response?

I recommend that you notify the child's pediatrician.

88. The nurse is preparing a client for a stress electrocardiogram. Which client statement requires further nursing teaching?

I will keep walking even if I feel exhausted."

20. After being diagnosed with type 2 diabetes, a client has expressed an intention to "turn over a new leaf and commit to a vigorous exercise regime. The nurse has emphasized the importance of having the client's fitness level assessed before beginning the exercise program. What is the main rationale for the nurse's advice?

Identify any risks for injury that might be posed by an exercise program.

56. A nurse is caring for a client diagnosed with sleep apnea. Which nursing diagnosis should the nurse include in her nursing care plan?

Impaired Gas Exchange

37. A nurse is caring for a 65-year-old clent who has been paralyzed from the waist down. The physiotherapist has prescribed ambulatory exercise, for which the nurse needs to monitor and assist the client. What would be an indication to the nurse that the activity is beyond the tolerance level of the client?

Increased heart rate

32. A nurse is observing the prescribed therapeutic activity of a middle-aged client who underwent a mastectomy to control her breast cancer. Which active exercises or therapeutic activities should the client perform?

Leam to comb her hair independently wth the arm on the surgical side.

53. A mother is talking with the community-based nurse concerning her adult son. The son is mentally challenged and not able to live on his own. The mother is concerned about her son's welfare when she is no longer able to care for him. What is the best response by the nurse?

Let's look into the community resources that are available to assist you."

38. The nurse is caring for a child with tonsillar enlargement. What is the nurse's priority

Low oxygen saturation

67. A client has been ordered to undergo a step test. Which arrangement is of greatest importance during a step test?

Make arrangements for cardiopulmonary resuscitation personnel.

81. A young wife is talking with the nurse about her husband who is retuming from the military. The wife confides that her husband is physically okay but is behaving differently. What is the nurse's best response?

Many times people need care for emotional trauma.

46. A pationt complains of not being able to fall asleep at night and asks the nurse if there is a safe. non-prescription medication he can try. After oonsulting the healthcare provider. the nurse should recommend which naturaly occurring hormone?

Melatonin

85. Based on the significant effects of chronic idiopathic fatique, what is the nurse's priority assessment?

Mental health evaluation

3. Many middle-aged adults are called the "sandwich" generation because they are caring for their children and their aging parents. What is the priority reason for aging parents needing care?

Multiple chronic illinesses

45. The nurse palpates swollen nodes in a patient's neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What the nurse's best action?

Notify the healthcare provider.

52. A nurse is caring for a patient who is diagnosed with narcolepsy. Which is the most serious consequence of this disorder?

Potential for injury

66. A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case?

Range-of-motion exercises

25. The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented What is the nurse's best action?

Re-assess the patient's orientation

72. The nurse is teaching a client with seasonal affective disorder about proper use of a full-spectrum light. Which teaching will the nurse include?

Sit within 3 feet of the light for approximately 2hrs soon after awakening

2. A nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which should the nurse plan to discuss with this patient?

Sleeping in the supine position

75 The nurse enters a patient's room and the patient starties easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likaly awaken from?

Stage 1

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

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

97. A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?

Take before 6:00 PM at night.

21. The nurse is caring for a client who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

Teach client's spouse to keep car keys in an undisclosed location at night

76. The community health nurse is assessing a family who has a chronically ill child. The child needs special care, and the nurse has to coordinate the care for the home setting. What behavior will the nurse assess for to know that the family can care for the child?

The family is willing to learn about the care and share the caregiving needs.

9. A patient is experiencing lack of sleep because of pain. Which is the most appropriate goal for this patient?

The patient will report feeling rested after awakening in the morning.

6. The caregiver of a preschool-age child tells the nurse, "I am afraid my child sleeps much," and reports that the child takes a daily 2-hour nap in addition to sleeping 12 hours Points: at night, What is the appropriate nursing response?

Your child should get 10-13 total hours of slep time in a 24-hour period."

12. A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing?

acute renal failure

89. A client visits a health care facility and reports that he falls askeep nearly immediately the evening but often awakens between 4 and 5 a.m The nurse should assess for:

alcohol consumption.

29. A nurse is teaching a patent various techniques to promote sieep. Which internal stimulus that most commonly interferes with sleep should the nurse include in the teaching?

bladder fullness

42. The occupational nurse is assessing an employee's vital signs at rest. Which finding requires nursing intervention?

blood pressure 140/90 mm Hg

34. The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem?

bradypnea

95. A nurse is examining and documenting the physical condition of a client who undergoing a prescribed stress electrocardiogram test at a health care facility. Which client observation should the nurse document?

breathing pattern

31. A nurse on the night shift notices that a client is grinding his teeth while sleeping. How should the nurse document the diagnosis for the client?bruxism

bruxism

33. A nurse is conducting an admission assessment of a client who has presented to hospital with complications of pregnancy. The nurse has asked the client to rate their perceived level of fitness. The nurse should be aware that fitness is defined as:

capacity to exercise.

51. An obese client has been advised to begin a program of fitness exercise. In preparation for the program, the nurse has taught the client the concept of metabolic energy equivalents (METS). An understanding of METS allos the client to:

compare the relative intensity of different forms of activity.

15. A nurse is caring for a client who recently underwent hip replacement surgery. What type of exercise should the nurse suggest for this client in order to restore muscle and joint functioning?

continuous passive motion machine

80. A patient has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated sleep deprivation should the nurse assess the patient?

delirium

44. A man with numerous comorbid health problems has presented to the clinic for a scheduled appointment. The man states that he has been awakening frequently during the night to void. The nurse should inquire about the time of day that the client is taking his prescribed:

diuretic

23. A nurse is caring for an older adult client who has been prescribed flurazepam by the physician. Which effect of flurazepam is a potential hazard for clients taking the medication?

drowsiness

90. A patient with chronic kidney disease is most likely to complain of whích symptom?

fatique

28. Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care?

fragmented sleep

64. A 78-year-old resident of an assisted living facility has told the nurse of often feeling tired during the day but experiencing frequent awakenings during the night. The nurse is conducting a comprehensive sleep assessment. The nurse should be aware of what change in sleep characteristic that acconmpanies older age?

increase in the proportion of REM sleep

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

is called slow wave sleep.

26. A physician has ordered an obese client to join an aerobic exercise class to promote cardiorespiratory conditioning. Which of the following fitness exercises is most suitable for the client?

isotonic exercise

59. A nurse is making a bed for a client confined to bed due to coma. Which position should the nurse place the client in to facilitate bedmaking?

lateral position

82. A patient is experiencing anxety. Which aspect of sleep should the nurse expect primarily will be affected as a result of the anxiety?

onset

69. A comatose client is being treated in the intensive care unit of a health care facility. What exercises should the nurse assist this client to perform in order to maintain the muscle tone and flexibility of the client's joints?

passive exercise

35. A nurse is caring for an older adult cient confined to bed who reports an inability to sleep. What activity should the nurse include in the client's plan of care to promote sleep?

performing chair exercises during the day

7A nurse is caring for a clent who is having difficulty breathing. Which bed accessory should the nurse use to provde a confortable position to the client?

pillows

14. A nurse is supervising a nursing assistant who is prepaning an occupied bed. What action by the nursing assistant indicates a nced for further learning?

pulling the draw sheet from below the client

8. A mother tells the nurse she is concerned because her 8 month old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response?

recommend that you notify the child's pediatrician.

87. A patient is experiencing discomfort associated with gastroesophageal refl ux. In which position should the nurse teach the patient to sleep?

semi-Fowler

22. A nurse is caring for an older adult client with chronic back pain and a sleeping disorder. The nurse suggests some relaxation techniques to be performed before bedtime. Which techniques should the nurse suggest?

sit in a rocking chair

98. A nurse is caring for a client at a health care facility who has been prescribed physical exercises by the physiotherapist. Which of the following beverages should the nurse eliminate for older adults before or during physical activities?

tea

4. A nurse at a health care facility is suggesting the use of isometric exercise to a client What is the major purpose of isometric exercise?

to increase lean muscle mass

68. A nurse is assisting a client in performing prescribed range-of-motion exercises. What is one of the reasons why these exercises are being performed?

to test a client's ability to bear weight

13. A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?

tossing soiled linen on the floor

19. The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action does the nurse identify that appropriately reflects these movements?

turns arms downward, then upward

11. The nurse recognizes that which patients are at highest tisk for physiologic fatigue? (Select all that apply.)

🔅Businessman who consumes six cups coffee/day 🔅25-ye ar-old pregnant female 🔅Adolescent with anorexia 🔅Parents of a newborn

91. The nurse is providing education to a community about creation of a safe exercise program. Which teaching will the nurse include? (Select all that apply.)

🔅Dress in layers according to temperature. 🔅See a healthcare provider prior to starting an exercise program. 🔅Wear supportive shoes. 🔅Build up to 30 minutes or more of moderate-intensity physical activity on most days.

78. Which are treatment related causes of fatigue? (Select all that apply.)

🔅Radiation therapy 🔅Surgery 🔅Chemotherapy 🔅Side effects of medications

10. A client reports to the nurse, "Sleep really isn't necessary" Which teaching by the nurse is appropriate? (Select all that apply.)

🔅Sleep helps your blood flow to the brain. " 🔅Sleep he lps you to learn easier and remember more. " 🔅Sleep helps your immune system to fight off infections."

47. Which concepts associated with rest and sleep must the nurse consider when planning nursing care? Select all that apply.

🔅Sleep requirements increase during stress. 🔅Lack of awareness of the environment increases with sleep.

58. The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.)

🔅Tenderness under the jaw 🔅Swollen, painful knees 🔅5episodes tonsillitis/past year 🔅Feeling tired upon awakening

63. A 12-year-old boy is experiencing nocturnal enuresis. Which strategies should the nurse explore with the boy and his parents? Select al that apply.

🔅Voiding immediately before going to bed 🔅Thinking about waking up dry when going to bed at night 🔅Limiting fluid intake after dinner 🔅Eliminating caffeinated beverages from the diet

62. The occupational health nurse is making rounds in a factory. Which employees need further education about conservation strategies?

🔅Workers standing for long periods 🔅Workers reaching up to high shelf often to obtain cleaning supplies 🔅Workers bending over to lift boxes onto conveyer belt

55. A patient is having diffi culty sleeping and may be experiencing shortened nonar apideye-movement (NREM) sleep. Which patient assessments support this conclusion? Select all that apply.

🔅excessive sleepiness 🔅decreased pain tolerance

39. An older female adult explains to the nurse that she has insomnia. The nurse interviews the patient and her husband and reviews the patient's medication reconciliation form Which factors does the nurse conclude are associated with the patient's insomnia? Select al that apply. Interview with Patient Patient reports having diffi culty falling asleep, waking frequently during the night, and having difficulty faling back to sleep. Patient states, "Inever feel rested in the morning." Interview with Patient's Husband mnute catnaps during the day. Encourage her to have a drink of whiskey to knock her out when she goes to bed. My wife's problem with sleeping has been going on for several months She is so tired duting the day that she takes sevejal 10 Medication Reconciliation Form Diphenhydramine 50 mg PO at hour of sleep Metformin 100 mg PO twce a day

🔅female gender 🔅alcohol intake 🔅older adult

48. Caregivers are often categorized by their relationship to the person being cared for. Which of the following are the roles? (Select all that apply.)

🔅grandparent 🔅adult children 🔅neighbor/triend 🔅parent 🔅spouse

100. The nurse is caring for a client who has undergone a mastectomy. Which example(s) of active exercise will the nurse emphasize? (Select all that apply.)

🔅instructing the client to swing a rope attached to a doorknob 🔅asking the client to squeeze a soft ball 🔅having the client comb hair with the arm on the surgical side

70. A nurse is caring for a patient who is having difficulty sleeping. Which patient responses indicate to the nurse that the patient is not obtaining adequate rapid-eyemovement (REM) sleep? Select all that apply.

🔅irritability 🔅confusion

36, The nurse is teaching a 37-year old clent about factors that impair fitness and stamina Which factors will the nurse dentify? (Select all that apply )

🔅obesity 🔅health problems 🔅age 🔅smoking

74. During discharge teaching with a client who has been treated for a hernia, the nurse has discussed the benefits of a regular regime of physical exercise. What benefits of regular exercise should the nurse cite? (Select all that apply.)

🔅reduced blood glucose levels 🔅decreased low-density blood lipids 🔅reduced blood pressure 🔅improved bowel function