EAQ'S

a nurse in the surgical intensive care unit is caring for a pt with a large surgical incision. the nurse reviews a list of vitamins and expects that which medication will be prescribed because od its major role In wound healing? A. Vitamin A (Aquasol A) B. Cyanocobalamin (Cobex) C. Phytonadione (Mephyton) D. ascorbic acid (ascorbicap)

Ascorbic acid (ascorbicap) Vitamin C (ascorbic acid) plays a major role in wound healing. it is necessary for the maintenance and formation of collagen, the major protein of most connective tissue.

Which part of the nursing is documented in discharge and transfer forms? A. Planning B. Diagnosis C. Assessment D. implementation

Assessment the assessment findings of the pt are documented in the discharge and transfer forms, progress notes, and flow sheets of the pt.

a nurse advises a pt to use a firm mattress for sleep and to refrain from sleeping on the abdomen. which condition does the pt most likely have? A. back sprain B. fibromyalgia C. rheumatoid arthritis D. ankylosing spondylitis

Back sprain Pt with a back sprain should be advised to use a firm mattress for sleep and to refrain from sleeping one the abdomen. to manage fibromyalgia, its should be taught the basic principles of good sleep hygiene, which do not necessarily include a firm mattress of prone position.

what is the results of increased dental caries in an older adult? A. decreased digestion B. decreased nutritional status C. increased incidence of pyrosis D. increased incidence of choking

Decreased nutritional status (increased dental caries in older adults can result in a deceased nutritional status.)

which intervention will help a pt prevent dental plaque and Caries? A. performing hand hygiene B. Drinking fluoridated water C. avoiding hot, cold and spicy foods D. eating 4-6 small meals daily

DrInking fluoridated water fluoridated water is used to prevent dental plaque and Caries.

a woman visits the clinic because she has dysmenorrhea. which goal is most realistic for this pt to achieve? A. reducing the pad saturation rate. B. Making intercourse less uncomfortable C. Easing the pain of the pts menstruation D. Eliminating bleeding between menstrual periods

Easing the pain of the pt's menstruations Dysmenorrhea is a a painful menstruation: the goal is making the menstruation less painful.

what is the first strategy for burnout prevention that deliberately reflects on the nurse's stress? A. focus B. choice C. balance D. awareness

Focus awareness is the first strategy of burnout prevention because it deliberately reflects on the stress in one's life.

which statement regarding anxiety is correct? A. panic is a chronic form of anxiety B. Anxiety trait is a learned response to an event such as test-taking C. Generalized anxiety disorder is characterized by a severe degree of avoidance behavior D. signal anxiety is associated with a feeling of dread with a source that cannot be identified

Generalized anxiety disorder is characterized by a severe degree of avoidance behavior.

while caring for a pt with UTI, the nurse manager delegated the work of administering oral meds. which delegates would be appropriate for this task? Select all that apply. A. CNA B. PCA- patient care associate C. LPN D. LVN E. UAP

LPN LVN

which type of temperature measurement is contraindicated in pt's with shaking chills? A. oral B. rectal C. axillary D. tympanic

Oral

Which factor in a pt's history increases the risk for osteoporosis? A. estrogen therapy B. hypoparathyroidism C. prolonged immobility D. excessive calcium intake

Prolonged immobility Prolonged immobility results in bone demineralization because there is decreased bone production by osteoblasts and increased resorption by osteoclasts.

the rehab team is caring for an older pt, who is completely immobile, with hx of knee replacement. which member of the team reinforces education about the processes of rehab provided to the pt and family members? A. Physical therapist B. Rehab RN C. vocational rehab counselor D. rehab LPN/LRN

Rehab LPV/LRN an elderly bedridden pt with hx of knee replacement may experience joint stiffness. it is a duty of a rehab LPN/LRN to reinforce education about the processes of rehab provided to the pt and family members.

a nurse is caring for a pt diagnosed with MRSA in the urine. the health are provider orders an indwelling urinary catheter to be inserted. which precaution should the nurse take during this procedure? A. droplet precautions B. reverse isolation C. surgical asepsis D. Medical asepsis

Surgical asepsis catheter insertion requesting sterile technique.

The nurse provides a pt with left-sided weakness with instructions on how to safely use a cane. the nurse should demonstrate proper use of the cane by holding it on which side(s)? A. Alternating side B. The right side C. The side with the weakness D. The side of the pt's choice

The right side the cane should be used on the stronger (unaffected) side of the body to add strength, decrease dependence on the weaker (affected) side, and aid in balance during ambulation.

a pt with diabetes was taught to self-administer insulin. which site should the pt choose for fast absorption? A. arms B. thighs C. buttocks D. abdomen

abdomen

which pt is at an increased risk for hearing loss? A. White B. Hispanic C. African American D. Native American

white

an RN is teaching a nursing student about interventions for a pt with nocturia who complains of fatigue. which statement indicated the nursing student needs further learning? A. "I'll advise pt to limit fluids at night" B. "I'll advise pt to perform pelvic floor exercises" C. "I'll advise pt to take diuretic medications in the morning" D. "I'll advise pt to remove rugs and furniture from walkways"

"I'll advise pt to perform pelvic floor exercises." (a nurse would advise pt's with stress incontinence tp practice pelvic floor exercises.)

a pt who visited the hospital reports sneezing, excessive nasal secretions, and itching eyes. on assessment, the condition is diagnosed as anaphylactic hypersensitivity. which cells act against this reaction? A. T-cells B. B-Cells C. neutrophils D. macrophages

B-Cells sneezing, excessive nasal secretions, and itching eyes are the signs of anaphylactic hypersensitivity reaction. this reaction is a humoral reaction and is considered as humoral immunity. B-cells are responsible for humoral immunity.

a primary health-care provider asks a nurse to encourage bed rest and to plan care to prevent fatigue in a pt. what condition might the pt have? A. pain related to ischemia B. Respiratory distress related to cardiac dysrhythmia C. Decreased cardiac output related to cardiac insufficiency D. Gastrointestinal complaints related to cardiac dysrhythmia

decreased cardiac output related to cardiac insufficiency the nurse should encourage bed rest and plan care for a pt to prevent fatigue due to decreased cardiac output related to cardiac insufficiency.

which predisposing condition may be present in a pt with pitting edema? A. shock B. kidney disease C. hypothyroidism D. severe dehydration

kidney disease kidney disease may be a predisposing condition associated with pitting edema.

a nurse observes regular patterns that look like they were made by a belt buckle, wire hanger, and chain on a child's skin. What behavioral change might the nurse also expect from the child? A. the child expresses fear of going home B. the child shows self-stimulatory behavior C. the child's intellectual development is lagging D. the child displays age-inappropriate sexual play

the child expresses fear of going home ( a child suffering from physical abuse is likely to express fear of going home.

a woman arrives at the women's health clinic complaining of frequency and during pain when voiding. The diagnosis is a urinary tract infection. what is important for the nurse to encourage the pt to do? A. void every 2 hours B. record fluid intake and urinary output C. pour warm water over the vulva after voiding D. wash the hands thoroughly after urinating and defecating

wash the hands thoroughly after urinating and defecating. Hand washing is a medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections is incorporated into the pt's health practices.

the nurse is teaching a pt with diabetes about foot care. which statements made by the pt indicates the pt understands which activities would be beneficial to prevent infection? select all that apply. A. " I will apply lotion to my feet daily." B. "I will Clean my feet with hot water." C. "I will cut my nails close to the nail bed." D. "I will soak my feet in water for at least 10 minutes before goin nail care." E. "I will assess the skin on my feet for redness, abrasions, and open areas daily."

- " I will apply lotion to my feet daily." - "I will assess the skin on my feet for redness, abrasions and open areas daily.

A terminally ill pt is coping with feelings regarding impending death. the nurse bases care on the theory of death and dying by Kubler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? A. Anger B. Denial C. Bargaining D. Acceptance

Acceptance communication and interventions during the acceptance stage are mainly nonverbal. the nurse should be quiet but available

which pt population requires increased screening and preventative education related to colorectal cancer? A. Asian American B. Native American C. African American D. Hispanic American

African American.

what should the nurse teach a pt who is taking antihypertensives to do minimize orthostatic hypotension? A. wear support hose continuously B. lie down for 30 minutes after taking medication C. avoid tasks that require high-energy expenditure D. sit on the edge of the bed for 5 minutes before standing

Sit on the edge of the bed for 5 minutes before standing sitting on the edge of the bed before staying up gives the body a chance to adjust to the effects of gravity on circulation in the upright position.

a nurse discusses the hospice Medicare benefit to a group of nursing students. which statement made by a nursing student indicates effective understanding of the benefit? A. "Hospice medicare benefits came into effect in 1985 to ensure quality hospice services." B. "Hospice medicare benefits cover all expenses for acute care including professional staff visits." C. "Hospice medicare benefits bereavement follow-up care for up to two years after the clients death." D. "Hospice medicare benefits requires verification from at least one primary health-care provider that the pt is dying."

"Hospice medicare benefits cover all expenses for acute care including professional staff visits."

a nurse is education the parents of toddlers about how to promote healthy sleep patterns in their children. which statement made by a parent indicates a need for further teaching? A. "I'll use quiet time activities before sleep." B. "I'll reassure my child that she is not alone." C. "I'll allow my child to have a favorite bedtime toy." D. "I'll keep telling stories to my child until she falls asleep."

"I'll keep telling stories to my child until she falls asleep." to promote a healthy sleeping pattern in the toddler, the parents should tell a specified number of stories the child rather than telling stories until the child falls asleep.

which action may cause lipohypertrophy in a client who is receiving insulin injections? A. injecting insulin subcutaneously B. storing insulin in the refrigerator C. using buffered regular insulin injections D. administering into the same site each time

administering insulin into the same site each time lipohypertrophy is a subq skin disorder in which a firm lump develops under the skin. injecting insulin into the same site each time may cause lipohypertrophy

a pt experiences a muscle sprain of the ankle. when assessing the injury, the nurse discovers a developing hematoma and edema. the pt reports tenderness when the ankle is palpated. the nurse anticipates that the plan of care will include the application of what? A. binder B. ice pack C. elastic bandage D. warm compress

ice pack applying ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain.

among the following pt's, which is at the highest risk for hepatitis infection? A. gay man B. bisexual man C. lesbian woman D. heterosexual woman

gay man sexual orientation is a factor that contributes to health disparities.

the nurse is explaining to a pt about self-administration of insulin. which format of DARE applies to this information? A. data B. action C. education D. response

education

the nurse is caring for a pt with ureteral colic. to prevent the development of renal calculi in the future, what should the pt's plan of care include? A. interventions to decrease the serum creatinine level. B. excluding milk products from the diet C. instructing the pt to drink 8-10 glasses of water daily D. a goal of 2000 mL/24 hours urinary output

instructing the pt to drink 8-10 glasses of water daily. increasing fluid intake dilutes the urine, and crystals are less likely to coalesce and form calculi.

a pt expresses concern about being exposed to radiation therapy because It can cause cancer. what should the nurse emphasize when informing the pt about exposure to radiation? A. the dosage is kept at a minimum B. only a small part of the body is irradiated C. the pt's physical condition is not a risk factor D. Nutritional environment of the affected cells is a risk factor

only a small part of the body is irradiated current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue.

a nurse in the post anesthesia care unit (PACU) is providing care to a pt who had abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. what is the next nursing action? A. change the dressing B. reinforce the dressing C. replace the take with Montgomery ties D. support the incision with an abdominal binder

reinforce the dressing anticipate reinforcing the dressing. changing a dressing at this time is unnecessary and increased the risk for infection.

Which nursing intervention would be beneficial to a pt with human immunodeficiency virus (HIV) infection who is experiencing fatigue A. recommending high-fiber foods B. scheduling ample periods of rest C. recommending dry and salty foods. D. encouraging fluid intake of more than 2.500 mL/day

scheduling ample periods of rest. to replenish energy

a nurse is responding to the needs of victims at a collapsed building. what principle guides the nurses priorities during this disaster? A. to same the most lives, hemorrhage necessitates immediate care. B. those requiring minimal care are treated so they can help others C. because the care is most complex, victims with head injuries are treated first D. children receive the highest priority because they have the greatest life expectancy.

those requiring minimal care are treated first so the can help others.

What is a function of a bereavement support group? A. filing of insurance papers B. providing drug consultation C. assisting in solving any problems between a caregiver and pt D. Providing families who have lost loved ones a chance to communicate and share their feelings

Providing families who have lost loved ones a chance to communicate and share their feelings.

after teaching a pt about a low fat diet, what is most important for the nurse to document? A. pt's weight loss goals B. pt's ability to plan a low-fat meal C. pt's receptiveness to the education D. education of family members/significant others as well as the pt

pt's ability to plan a low-fat meal Documenting the pt's ability to plan a low-fat meal demonstrates the pt's ability to apply the education to lifestyle.

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to do what? A. prevent infection of the wound B. increase fluid loss from the skin C. reduce inflammation at the surgical site D. limit itching around the area of the lesion

reduce inflammation at the surgical site steroids are used for their anti-inflammatory, vasoconstrictive, and antipruritic effects. steroids increase the incidence of infections because they are anti-inflammatory agents and mask symptoms of infection. steroids increase fluid retention because they promote the reabsorption of sodium form the tubular fluid the plasm.

five days after a pt has abdominal surgery a nurse assesses the pt's incision site for signs of dehiscence. which clinical finding supports the nurse's conclusion that the pt is experiencing wound dehiscence? A. increased bowel sounds. B. loosening of the sutures C. serosanguineous drainage D. purplish color of the incision

serosanguineous drainage serosanguineous drainage from the wound or on the dressing forewarns about separation of the wound edges (dehiscence); Dehiscence may progress to the movement of abdominal organs outside of the abdominal cavity (evisceration).

a nurse is taking the health history of a pt who is to have surgery in one week. the nurse identifies that the pt is taking IBU for discomfort associated with osteoarthritis and notifies the healthcare provides. which drug does the nurse expect will most likely be prescribed instead of IBU A. naproxen B. aspirin C. ketoralac D. acetaminophen

Acetaminophen Acetaminophen is a nonopiod analgesic that inhibits prostaglandins, which serve as mediators for pain; it does not affect platelet function.

what parameter does the nurse assess first while assessing a client with severe trauma? A. Airway B. Disability C. Breathing D. Circulation

Airway (airway is the first assessed in a pt with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death.

which treatment strategy is beneficial for a pt with panic disorder? A. Milieu Therapy B. Debriefing technique C. Confrontation therapy D. electroconvulsive therapy.

Debriefing technique the debriefing technique is often used to treat panic disorder.

the pt is about to leave the hospital, with home health nursing. where should the nurse document the physiologic status of the pt? A. flow sheets B. progress notes C. pt care plan D.discarge and transfer forms

Discharge and transfer forms

Which self-care behavior would benefit a pt with GERD A. Limiting alcohol intake B. avoiding protein-rich foods C. eating two small meals a day D. Consuming small evening snacks

Limiting alcohol intake a pt with GERD should limit/avoid alcohol

which pt-made, the legally enforceable document contains the instructions of the pt regarding his/her refusal to receive cardiopulmonary resuscitation upon admission to a hospital for surgery? A. Informed consent B. Occurrence basis policy C. Resident Assessment D. Physician Orders for Life-Sustaining Treatment (POLST)

Physician Order for Life-Sustaining Treatment (POLST) Physician Order for Life-Sustaining Treatment (POLST) is a type of legally enforceable document that contains the pt's wishes regarding health care. It is formed when he/she is alive and competent and is enforceable in a situation when he/she is incapacitated and unable to make decisions. one being DNR

a child with acute post streptococcal glomerulonephritis requests a snack. which is the most therapeutic selection of food the nurse can provide? A. peanuts B. pretzels C. bananas D. applesauce

applesauce (provides nutrition without large additional amounts of potassium and sodium)

a patients chest tube has accidentally dislodged. what is the nursing action of highest priority? A. place the client in a left Side-lying position B. apply oxygen via nonrebreather mask. C. apply a petroleum gauze dressing over the site. D. prepare to reinsert a new chest tube

apply a petroleum gauze dressing over the site. (petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. the petroleum gauze should be taped only onto three sides to allow for excessive air to escape, preventing a tension pneumothorax.)

which action should be the nurse's first priority for a pt with major burns? A. assessing airway patency B. checking the pt from head to toe C. administering oxygen as needed D. elevating the extremities if no fractures are noticed

assessing airway patency the first action of the nurse for a pt with major burns should be assessing airway patency because airway obstruction will lead to the death of the pt.

which laboratory test result will be elevated in a pt with inflammatory arthritis? A. leukocyte count B. hemoglobin and hematocrit C. blood urea nitrogen and creatinine D. Erythrocyte sedimentation rate (ESR)

erythrocyte sedimentation rate (ESR) ESR measure the rate at which RBC fall through plasma. this rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. an ESR >20mm/hr indicates inflammation or infection somewhere in the body. ESR is chronically elevated with inflammatory arthritis.

a pt reports frequent awakening at night, insomnia, and excessive daytime sleepiness. the pt added that his bed partner also complains about his loud snoring. what does the nurse anticipate including in the pt's teaching plan? A. take a warm shower before bedtime B. take a sedative three or four hours before bedtime C. avoid alcoholic beverages for five to six hours before bedtime D. get fitted for an oral appliance that will bring the lower jaw and tongue forward

get fitted for an oral appliance that will bring the lower jaw and tongue forward Frequent awakening at night, insomnia, excessive daytime sleepiness, and loud snoring indicate obstructive sleep apnea. to help to pt manage obstructive sleep apnea, the nurse may suggest that he get fitted for an oral appliance that will bring the mandible and tongue forward to enlarge the airway space. this will prevent airway occlusion.

a pt with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. what increased risk does the nurse consider when assessing this client? A. weight loss B. hypoglycemia C. decreased blood pressure D. inadequate wound healing

inadequate wound healing because the anti-inflammatory response is depressed as a result of increased cortisol levels, the wounds of pts receiving long-term corticosteroid therapy tend to heal slowly.

which dietary suggestion should the nurse provide while teaching a group of geriatric female pt's who have reduced amounts of circulating estrogen? A. include fish in your diet B. include fruits in your diet C. include yogurt in your diet D. include legumes in your diet

include yogurt in your diet. females usually attain menopause at the age of 55 years. due to reduced amounts of circulating estrogen in postmenopausal women, bone density decreases, this increasing the risk of osteoporosis.Geriatric pts should be advised to consume foods rich in calcium such as yogurt, which helps support increases in bone mass.

which statement regarding Rheumatoid Arthritis is true? A. it is a systemic condition B. it affects the hips and knees C. it involves bone spur formation D. if affects males and females equally.

it is a systemic condition (RA is a systemic condition that involves inflammation of synovial membranes and destruction of bones, ligaments, tendons, cartilage, and joint capsules. RA affects females more that men. 3:1 ratio)

a nurse takes the rectal temperature of a pt with an electronic thermometer. what should the nurse do to ease the insertion? A. assist the pt into sims position B. Lubricate one inch of the thermometer tip C. Hold the electronic problem until an audible signal occurs D. slide the disposable plastic cover over a thermometer probe

lubricate one inch of the thermometer tip lubricating one inch of the thermometer tip will ease the insertion of the instrument into the rectum.

what is the priority during intervention for a forgetful, disoriented pt with the diagnosis of dementia of the Alzheimer type? A. restricting gross motor activity B. preventing further deterioration C. keeping the pt oriented to time D. managing the pt's unsafe behaviors

managing the pt's unsafe behaviors pt's with Alzheimer disease require external controls to minimize the danger of injury cause by lack of judgement.

a pt with a 20 yr hx of excessive alcohol use is admitted to the hospital with jaundice and ascites. what is the priority nursing action during the first 48 hours after the pt's admission? A. Monitor the pt's vital signs. B. increase the pt's fluid intake C. improve the pt's nutritional status D. determine the pt's reasons for drinking

monitor the pt's vital signs. a pt's vital sings, especially the pulse and temperature, will increase before the pt demonstrates any of the more severe sx of withdrawal from alcohol.

the nurse is caring for a pt undergoing chemotherapy for cancer treatment. the pt's lab results indicate bone marrow suppression. what should the nurse encourage the client to do? A. use an electric razor when shaving B. Drink citrus juices frequently for nourishment C. increased activity level by ambulating frequently D. sleep with the head of the bed slightly elevated

use and electric razor when shaving suppression of bone marrow increases bleeding susceptibility associated with decreased platelets.

a nurse preparing to apply restraints to a pt should understand which of the following principles? A. the law prohibits restraining its until a written prescription is obtained B. charges of felony may be leveled against nurses who use restraints improperly C. nurses are not obligated to report institutions that use restraints unlawfully D. charges of assault and battery may be leveled against the nurses who use restraints improperly

charges of assault and battery may be leveled against nurses who use restraints improperly.

a 65 y/o pt is depressed and has dementia. which health-care facility would be most beneficial for the pt? A. respite-care facility B. hospice-care facility C. palliative-care facility D. long-term care facility

long-term care facility a long-term care facility would be most beneficial for apt who suffered dementia and depression. most residents of long-term care facilities have more than one health disorder when they are admitted.

while educating a pt about the stages of non-rapid eye movement (NREM) sleep, a nurse says, "sleepwalking and bedwetting are possible during this stage." to which stage is the nurse referring to? A. stage 1 B. stage 2 C. stage 3 D. stage 4

stage 4

a pt with diabetes is self-administering insulin. which action performed by the pt indicated a need for correction? A. inspecting the vial for crystals B. washing hands with hot water C. inspecting the barrels for air bubbles D. bringing the insulin to room temp

washing hands with hot water pt should perform hand washing with warm water before administering insulin to reduce contaminiation

which statement is true regarding the reconstruction phase of wound healing? A. wound dehiscence mostly occurs in the reconstruction phase B. the reconstruction phase begins on the 2nd day and lasts for 2-3 days C. collagen formation increases rapidly between post operative days 1 and 5 D. during the reconstruction phase, the wound takes the form of a light pink, matured scar.

wound dehiscence mostly occurs in the reconstruction phase reconstruction phase begins on the third or fourth day and lasts for 2-3 weeks. collagen formation increases rapidly between 5-25 days after surgery. during reconstruction phase, the wound takes the form of a purplish scar.

the health-care provider is discussing the nursing home facilities with a new member of the staff. which statement made by the staff members indicates the need for further discussion? A. "A nursing home setting should resemble a hospital." B. "the nursing home facility is meant to restore functional abilities to its pts." C. "The client rooms are designed with ample, non glare lighting." D. "The facility encourages residents to personalize their rooms."

"A nursing home setting should resemble a hospital."

the RN is teaching a nursing student about health maintenance organizations (HMO). which statement made by the nursing student indicates the need for further discussion? A. The pt or employer pays a monthly fee for insurance B. HMOs are a type of group practice that enrolls pt for a set fee per month C. the two national HMOs are Kaiser Permanente and United States Family Health Plan. D. HMOs provide an unlimited network of physicians, hospitals, and other health-care providers.

Health maintenance organizations (HMO) provide an unlimited network of physicians. hospitals, and other health-care providers Health maintenance organizations (HMO) provide a limited, not unlimited, network off physicians, hospitals and other health-care providers.

a carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever." what is the nurse's best initial response? A. "the staff is taking steps to minimize scarring." B. "think about how lucky you are. you are alive" C. "try not to worry for now. Concentrate on your range-of-motion exercises." D. "I know you're worries, but it is too early to tell how much scarring will occur."

"I know you're worried, but it is too early to tell how much scarring will occur." it's the truthful answer and validates the pt's feelings.

An RN evaluates the statements made by a new nurse about time management while delegating pt care. which statement made by the new nurse indicates need for further instruction? A. "I should discuss issues with my colleagues." B. "I should keep track of the time I utilize while performing activities." C. "I should establish priorities based upon the schedule time frames." D. "I have to attend pt-care conferences and give staff reports on time."

"I should discuss issues with my colleagues." the nurse should discuss issues with colleagues during reports, meal breaks, or team meeting to prevent an interruption of pt care activities.

a pt who has been taking IBU for RA ask the nurse if acetaminophen can be substituted instead. what is the appropriate nursing response? A. "Acetaminophen is the preferred treatment for RA." B. "Acetaminophen irritates the stomach more than IBU does." C. "IBU has anti-inflammation properties and acetaminophen does not." D. "yes, both are antipyretics and have the same effect."

"IBU has anti-inflammatory properties and acetaminophen does not." IBU has an anti-inflammatory action that relieves the inflammation and pain associated with arthritis. acetaminophen is not a NSAID. NSAID are preferred for the treatment of RA.

A parent receive a note from school reporting that a student in class has head lice. the parent calls the school nurse to ask how to check for head lice. what instruction should the nurse provide? A. "Ask the child where it itches." B. "check to see whether your dog has ear mites." C. "look at your child's head along the scalp for white dots." D. "inspect your child's hands and look between the fingers for red lines."

"Look at your Child's head along the scalp line for white dots." The white dots are nites, the eggs of head lice (pediculosis capitis) they can be seen on the shaft of hair along the scalp line, behind the ears and the nape of the neck."

a pt with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the pt has been taking any medications, the pt replies. "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different so I decided I'd only take them when I feel sick." what is the best initial response by the nurse? A. "You must be quite frightened about having high blood pressure." B. "I'm glad to hear you have felt well enough to stop the medication." C. "it is important to take your medications daily to achieve optimal results" D. "you will need to document daily whether you took your medication or not."

"it is important to take your medications daily to achieve optimal results." it is a nonjudgemental response that does not pressure the pt but does indicate clearly that treatment is necessary.

while educating a group of nursing students about the various effects of commonly abused substances, a nurse explains delirium tremens (DT's). which statement by a student indicates effective understanding? A. "it may cause damage in the temporal lobes to the clients brain." B. "it can be treated by supporting ventilation and administering naloxone as prescribed." C. "it's characterized by short-term memory loss, disorientation, muttering and delirium." D. "it often occurs one to four days after cessation of alcohol use and lasts from two days to a week"

"it often occurs one to four days after cessation of alcohol use and lasts from two days to a week." (Delirium tremenes (DT's) is a complication of alcohol withdrawal. is it an acute psychotic reaction that results from cessation of excessive alcohol consumption after a long period of abuse. DTs most often occur one to four days after cessation of alcohol use and last two days to a week)

a nurse is hired to work in a health care facility that has a complete computer based pt info system. what statement by the newly hired nurse indicated that this nurse is knowledgable about this system? A. "more medication errors are made when this system is used" B. "it's disappointing that nurses are not allowed to use this system" C. "pt info is immediately available when the system is used" D. "I will have less time to provide direct care to my pt's with this system"

"pt info is immediately available when this system is used" (the intent of these systems is to streamline documentation and record-keeping for all appropriate health team members, including nurses. there is a reduction in medication errors with this type of system. data is immediately available to appropriate health team members without the need to depend on record/chart availability)

an 80 y/o pt is admitted to the hospital because of complications associate with severe dehydration. the pt's daughter asks the nurse how her mother could have become dehydrated because she is alert to the ability to care for herself. what is the nurse's best response? A. "the body's fluid needs decrease with age because of tissue changes" B. "access to fluid may be insufficient to meet the needs of the older adult." C. "memory declines with age and the older adult may forget to ingest adequate amounts of fluid." D. "thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased"

"thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased" (for the reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a decline in fluid intake."

a nurse is completing the health history of a pt admitted to the hospital osteoarthritis. the nurse expects the pt to report that which joints were involved initially? Select all that apply. A. Hips B. Knees C. Ankles D. Shoulders E. Meetacarpals

- Hips - Knees Osteoarthritis affects the weight bearing joints first because they bear the most body weight. the resulting joint damage cause a series of physiologic responses that lead to more damage.

the RN is explaining basic rules for documentation to a LPN. which statements made by the LPN indicate effective learning? select all that apply. A. "I will use generalized empty phrases." B. "I will fill the chart at the end of my shift." C. "I will leave few empty lines in the chart." D. "I will document the details when observed." E. "I will record in the chart using black ink pen."

- I will document the details when observed - I will record in the chart using black ink pen.

a nurse is caring for a pt who just had major abdominal surgery. what pt responses indicate the possibility of developing a superficial venous thrombosis? select all that apply? A. pitting edema of the ankle B. reddened area at the ankle C. pruritus on the side of the calf D. tender area in the posterior lower leg E. Warmth along the course of the involved vessel

- Tender area in the posterior lower leg - warmth along the course of the involved vessel thrombophlebitis, not uncommon after abdominal surgery, is inflammation of vein; it is associated with the formation of a clot (thrombus) in vein in the leg. findings associated with thrombophlebitis include pain, redness, swelling, and heat. warmth along the course of the involved vessels is related to the inflammatory process accompanying the thrombus.

a RN supervises a LPN who is caring for a pt with hyperthermia. which action by the LPN may indicate a need for further supervision? select all that apply A. advising the pt to increase physical activities. B. encouraging the pt to increase oral fluid intake C. keeping bed linens wet to reduce the pt's temperature D. removing the pt's external covering if temperature is subnormal E. Administering acetaminophen as ordered by the health-care provider

- advising the pt to increase physical activities - keeping bed linens wet to reduce the pt's temperature. - removing the pt's external coverings if the temperature is subnormal.

what are the priority nursing interventions for a grieving pt? select all that apply. A. recording pt details B. allowing the pt to express feelings C. monitoring the psychologic behavior of the pt D. counseling the family members about diet modifications E. respecting the feelings of the pt and creating a comfortable environment

- allowing the pt to express feelings -respecting the feelings of the pt and creating a comfortable environment. the priority nursing interventions for a pt in grief includes providing an environment that allows the pt to express his/her feelings, such as anger, fear, and guilt. respecting the pt's privacy and need/desire to talk (or not) is important and helps create a comfortable environment.

a pt has a diagnosis of hemorrhoids. which S/S does the nurse expect the pt to report? Select all that apply A. flatulence B. anal itching C. blood is stool D. rectal bulging E. pain when defecating

- anal itching - blood in stool - rectal bulging - pain when defecating

A nurse is taking care of a pt who has chronic, severe back pain as a result of a work injury. What nursing considerations should be made when determining the pt's plan of care? Select all that apply. A. ask the pt about the acceptable level of pain B. eliminate all activities that precipitate the pain C. administer the pain medication regularly around the clock D. use a different pain scale each time to promote patient education. E. Assess the pt's pain every 15 minutes

- ask the pt about the acceptable level of pain - administer the pain medications regularly around the clock the nurse works together with the pt in order to determine the tolerable level of pain. considering that the pt has chronic, not acute, pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. administration of pain medication around the clock will provide a stable level of pain medication in the blood and relieve the pain.

What is a nurse's responsibility when administering prescribed opiod analgesics? Select all that apply. A. Count the pt's respirations B. Document the intensity of the pt's pain C. withhold the medication if the pt reports pruritus D. verify the number of doses in the locked cabinet before administering the prescribed dose. E. Discard the medication in the pt's toilet before leaving the room If the medication is refused

- count the pt's respirations - Document the intensity of the pt's pain. - verify the number of doses in the locked cabinet before administering the prescribed dose.

a nurse caring for a hospitalized woman begins to suspect during assessment that the woman is experiencing domestic abuse. which behavioral findings might lead to nurse to this suspicion? select all that apply. A. depression B. suicide attempts C. chronic pelvic pain D. urinary tract infections E. Irritable bowel syndrome

- depression -suicide attempts behavioral signs and symptoms that may indicate a woman is a victim of domestic violence include depression and suicide attempt.

A nurse is providing colostomy care to a pt with a nosocomial infection caused by methicillin0resistant Staphylococcus aureus (MRSA). which person protective equipment should the nurse use? select all that apply A. gloves B. gown C. mask D. goggles E. show covers F. Hair bonnet

- gloves - gown - goggles standard personal protective equipment (PPE), which should be used for performing colosomy care in a pt positive for MRSA which is gloves, gown, and goggles

the nurse is caring for a dying pt. which interventions should the nurse implement for the client and family? Select all that apply A. arrange for the restorative care B. help the family set up home care if required C. refrain from telling the family that the pt is dying D. know the pt and family's strength and weaknesses E. Arrange for church or community support for the family

- help the family set up home care is required - know the pt and the family's strengths and weaknesses. - arrange for the church or community support for the family. because some dying patients prefer to be at home with the family during their last days, the nurse should help the family set up home care is required. the nurse should also know the pt and family well to be able to provide pt-centered care. the nurse should arrange for church or community support to help the pt and family during this difficult time.

while recovering from abdominal surgery a pt develops thrombophlebitis. which clinical indicators of this complication should the nurse expect to identify when assessing the pt? Select all that apply. A. pain in the calf B. intermittent claudication C. redness in the affected area D. putting edema of the lower leg E. Echhymotic areas around the ankle F. Localized warmth in the lower extremity

- pain in the calf - Redness in the affected area - localized warmth in the lower extremity pain is related to the edema associated with the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation a clot. Warmth is related to vasodilation.

what are the desired outcomes that the nurse expects when administering a nonsteriodal antiinflammatory drug (NSAID)? select all that apply. A. diuresis B. pain relief C. antipyresis D. bronchodilation E. anticoagulation F. reduced inflammation

- pain relief - antipyresis - reduced inflammation prostaglandins accumulate at the site of an injury, causing pain, NSAID inhibit COX-1 and COX-2 (both are isoforms of enzyme cyclooxygenase) which inhibit the production of prostaglandins, thereby contributing to analgesic. NSAIDS inhibit COX-2, which is associated with fever, thereby causing antipyresis, reducing inflammation.

which nursing actions are most appropriate when documenting the details of a pt's care in a chart? select all that apply. A. preparing the chart after providing care B. signing each block of the pt's charting C. asking a friend to prepare the chart for you D. indenting the left margin while documenting E. Documenting the chart based on the pt's opinion

- preparing the chart after providing care - signing each block of the pt's charting.

A nurse who is talking to a pt suspects the pt has agoraphobia. which of these responses by the pt support the nurse's suspicion? select all that apply. A. the pr repeats words frequently. B. the pt is afraid to walk in parking lots C. the pt is withdrawing from friends and family D. the pt is afraid to venture out of the house alone E. the pt refuses to use a public bus for transportation

- the pt is afraid to walk in parking lots - the pt is afrad to venture out of the house alone. - the pt refuses to use a public bus for transportation. fear of walking in open spaces such as parking lots, malls, or on bridges indicates that the pt has agoraphobia. the nurse suspects agoraphobia in the pt who is afraid to venture out alone, because a fear of not receiving help if an attack were to occur in a public place. they avoid settings like public transportation, that could be the scene of an attack.

a pt's diet is modified to eliminate food that act as cardiac stimulants. which foods will the nurse instruct the pts to avoid? select all that apply A. iced tea B. red meat C. club soda D. Hot cocoa E. Chocolate pudding

-Iced tea -hot cocoa chocolate pudding anything that contains caffeine. it is a cardiacs stimulant that should be avoided.

what is the max amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as brain attack) to remain in one position? A. 1-2 hours B. 3-4 hours C. 15-20 minutes D. 30- 40 minutes

1-2 hours change of position at least every 1-2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility.

an older pt reports fatigue, restlessness, insomnia, slowed speech, and anxiety lasting longer than two weeks. which disease does the nurse suspect? A. nocturia B. dementia C. depression D. Huntington disease

Depression symptoms such as fatigue, restlessness, enduring anxiety, insomnia, and slowed speech are manifestations of depression in older adults.

A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. which substance is most important for the nurse to determine if the pt is taking because it intensifies the most serious adverse effect of acetaminophen? A. Alcohol B. Caffeine C. Saw palmetto D. St. John's wort

Alcohol Too much ingestion of alcohol can cause scarring and fibrosis of the liver. 85-95% of acetaminophen is metabolized by the liver. acetaminophen and alcohol are both hepatotoxic substances. metabolites of acetaminophen, along with alcohol, can cause irreversible liver damage.

a pt's diagnosed with pancytopenia caused by chemotherapy. what should a nurse teach the pt about this complication? A. begin a program of meticulous mouth care B. avoid traumatic injury and exposure to infection C. increase oral fluid intake to at least 2L/day. D. report unusual muscle cramps or tingling sensation in the extremities

Avoid traumatic injury and exposure to infection Reduced platelets increase the likelihood of uncontrolled blueing; reduced lymphocytes increase the susceptibility to infection.

a pt is dx with AIDS. when examining the pt's oral cavity, the nurse assesses white patchy plaques on the mucosa. the nurse recognizes that the finding most likely represents what opportunistic infection? A. Cytomegalovirus B. Histoplasmosis C. Candida albicans D. Human papillomavirus

Candida albicans white patchy plaques on the oral mucosa would most likely be a results of C. Albicans, a yeastlike fungal infection. this condition is also known as "thrush".

A nurse is applying a dressing to a pt's surgical wound using a sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. what physical principle is applicable for caring for the sterile field to become contaminated? A. dialysis B. osmosis C. Diffusion D. Capillary

Capillary (when a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. the absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid the threads.)

what is the results of increased dental caries in an older adult? A. decreased digestion B. decreased nutritional status C. increased incidence of pyrosis D. increased incidence of choking

Decreased nutritional status increased dental caries in older adults can results in a decreased nutritional status.

When caring for a client with pneumonia, what nursing intervention is the highest priority? A. increase fluid intake B. Employ breathing exercises and controlled coughing C. ambulate as much as possible D. maintain a NPO status

Employ breathing exercises and controlled coughing (most pt's dx with pneumonia the most effective means of preventing fluid consolidation is to keep active by deep breathing and controlled coughing exercises)

When assessing a pt's abdomen, the nurse palpates the area directly above the umbilicus. what is this area known as? A. iliac area B. epigastric area C. hypogastric area D. suprasternal area

Epigastric area the stomach is located within the sternal angle, known as the epigastric.

which physical finding is most likely to be observed in an abused older adult? A. hematomas B. human bites C. genital injuries D. blood on the underclothing

Hematomas (hematoma are the most likely to be seen in older adult abuse. human bites are more commonly found in intimate partner violence. genital injuries and blood on clothing are more common physical findings in sexual abuse.)

the LPN is discussing the various record-keeping forms with a nursing student. which statement made by the nursing student indicate a need for further teaching? A. "I should use the Rand system to consolidate the pt's orders." B. "I should mention that I filled an incident report in the pt's during notes." C. "I should use the acuity charting system to rate each by the severity of the illness." D. "I should use a 24-hour record-keeping system to avoid unnecessary record-keeping forms"

I should mention that I filed and incident report in the pt's nursing notes. incident reports should not be included in the nursing note .

a LPN is providing palliative care to a pt who has undergone surgery as a measure to treat lung cancer. a RN teaches the LPN the interventions that need to performed if ineffective airway clearance related to the surgery develops in the pt. which statement by the nurse indicated a need for further teaching? A. "I'll promote coughing and deep breathing." B. "I'll assist the pt with frequent position changes." C. "I'll encourage the pt to use an incentive spirometer." D. "I'll facilitate optimal breathing by placing the pt in supine position."

I'll facilitate optimal breathing by placing the pt in supine position.

A nurse working in a postoperative ward assists an older pt in getting to the washroom in order to prevent the pt from falling. which level of need did the nurse prioritize in the pt according to Maslow's hierarchy of needs? A. level 1 B. level 2 C. level 3 D. level 4

Level 2 a nurse who assists an older pt in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs.

a pt is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. what should the nurse to help prevent the pt from developing urinary tract infection? A. assess urine specific gravity B. collect a weekly urine specimen C. maintain the prescribed hydration D. empty the drainage bag once a day

Maintain the prescribed hydration (promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection.)

which action is appropriate while assessing the body temperature in a pt who is suspected of having hypothermia? A. measuring oral temperature with class thermometer B. measuring rectal temperature with an electronic thermometer C. measuring axillary temperature with an electronic thermometer D. measuring tympanic temperature with a tympanic thermometer

Measuring rectal temperature with an electronic thermometer temperature assessed via the rectal route provides an accurate core temperature reading.

as an acute episode of RA subsides, active and passive range-of-motion- exercises are taught to the pt's spouse. the nurse should teach that direct pressure should not be applied to the pt's joints because doing so may precipitates what? A. pain B. swelling C. nodule formation D. Tophaceous deposits

Pain palpation will elicit tenderness, because pressure stimulates nerve endings and causes pain

a pt's with inflammation of the membranous sac surrounding the heart has muscle aches, fatigue, and dyspnea. the pt's reports chest pain that radiates to the shoulder and neck. which condition does the pt have? A. pericarditis B. endocarditis C. hypertension D. arteriosclerosis

Pericarditis it is an inflammation of the membranous sac surrounding the heart. symptoms include muscle aches, fatigue dyspnea, and chest pain that radiates to the shoulder and neck.

while caring for a child, a nurse found that the child is often hospitalized with injuries and infections. on further assessment, the nurse notes that the child is malnourished. what could be the reason for the child's condition? A. severe illness B. improper growth C. physical neglect D. emotional maltreatment

Physical neglect (children who are physically neglected may be malnourished, display developmental delays, or prone to frequent injuries and infection.

A pt is being treated for pressure ulcers. the primary healthcare provider advises the pt to eat foods with high amounts of Vitamin C. What is the role of vitamin C in wound healing? A. Vitamin C aids in the process of epithelialization. B. Vitamin C helps in the synthesis of immune factors C. Vitamin C increases the metabolic energy required for inflammation D. Vitamin C is required for collagen production by fibroblasts

Vitamin C is required for collagen production by fibroblasts Vitamin C aids in capillary synthesis and collagen production by fibroblasts. Vitamin A aids in process of epithelialization. protein helps in the synthesis of immune facts. carbohydrates increase the metabolic energy required for inflammation

a pt with a coronary occlusion is experiencing chest pain and distress. what is the primary reason that the nurse should administer oxygen to this pt? A. prevent dyspnea B. prevent cyanosis C. increase oxygen concentration to heart cells D. increase oxygen tension in the circulation blood

increase oxygen concentration to heart cells administration of oxygen increases the oxygen supply to the heart and improve cardiac output, which may prevent dyspnea.

after treatment for a bladder infection, a pt asks whether there is anything she can do to prevent cystitis in the future. what is the best response by the nurse? A. "avoid regular use of tampons" B. "decrease your intake or prune juice" C. "increase your daily fluid consumption" D. "cleanse the perineum from back to front"

increase your daily fluid consumption (increasing fluid intake flushes the urinary tract of microorganisms. )

a pt is receiving dexamethasone to treat acute exacerbation of asthma. for what side effect should the nurse monitor the client? A. hyperkalemia. B. liver dysfunction C. orthostatic hypotention D. increased blood glucose

increased blood glucose (dexamentasone increases gluconeogensis, which may cause hyperglycemia.)

a nurse is caring for an older bedridden male client who is incontinent of urine. which action should the nurse take first? A. restrict fluid intake B. offer the urinal regularly C. apply incontinence pants D. insert an indwelling urinary catheter

offer the urinal regularly (offering the urinal is the 1st step. restraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce ad conditioned response.)

which musculoskeletal condition occurs in part as a result of deficiencies in vitamin C and calcium? A. osteoporosis B. osteoarthritis C. ankylosing spondylitis D. fibromyalgia syndrome

osteoporosis (makes bones brittle and fragile as a result of deficiencies in vitamin D and calcium.)

which is a clinical manifestation of osteoarthritis? A. inflammation of the joints. B. pain and stiffness of the joints C. top around the rim of the ear D. Generalized ashiness in the Lower back

pain and stiffness of the joints.

a pt appears depressed since the surgical creation of a colostomy five days ago. the nurse determines that there is some movement toward adaptation to the change in body image when the pt exhibits which behavior? A. discusses the necessity of the colostomy B. requests the nurse to change the dressing C. looks at the nurse during care D. stares at the stoma during dressing changes

stares at the stoma during dressing changes a willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image.

a nurse is obtaining a health history from a pt with newly diagnosed cervical cancer. which aspect of the pt's life is most important for the nurse to explore at this time? A. sexual history B. support system C. Obstetric history D. elimination patterns

support system during a health crisis the pt will need support from significant others.

the nurse is preparing discharge instructions for a pt that acquired a nosocomial infection, Clostridium difficile. what should the nurse include in the instructions? A. anticipate that nausea and vomiting will continue until the infection is no longer present. B. the infection causes diarrhea accompanied by flatus and abdominal discomfort. C. consume a diet that is high in fiber and low in fat. D. other than routine hand-washing, it is not necessary to perform special disinfection procedures.

the infection causes diarrhea accompanied by flatus and abdominal discomfort. the main clinical manifestation of C.Diff is diarrhea accompanied by flatus and abdominal discomfort.

which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? A. the nurse should minimize the use of tape on the skin B. the nurse should keep the pt adequately hydrated C. the nurse should change the dressing as soon as they get wet D. the nurse should provide rest for the pt throughout the day

the nurse should keep the pt adequately hydrated. the best practice of the nurse to improve perfusion of the wound to promote healing for an older pt after surgery is to keep the pt adequately hydrated.

a pt with dementia is admitted with a fractured hip after a fall at home. the pt's family member witnesses the fall. four hours after admission, the pt's BP increases to a moderately severe hypertensive level. the pt pulls on the bedclothes continuously. the pt's family member asks for pain medication for the pt. what does the nurse conclude? A. the pt needs to go to the bathroom. B. the pt may be in pain and unable to respond appropriately C. the family member may be trying to keep the pt overmedicated. D. the family member feels guilty about the fall and wanted to keep the pt pain free.

the pt may be in pain and unable to respond appropriately. the pt's dementia indicates that the pt has problems with thought processes and may not be able to interpret or communicate the presence of pain.

the nurse creates a plan of care for a pt with risk of infection. which is the most desirable expected outcome for the pt? A. all nursing functions will be completed by discharge B. all invasive intravenous lines will remain patent C. the pt will remain awake, alert, and oriented at all times D. the pt will be free of S/S of infection by discharge.

the pt will be free of S/S of infection by discharge. whenever a pt has an infection or is at risk for infection, the nurse's primary onjfective in providing care is to prevent infection or perform activities that will promote the pt's being free from infection by the time of discharge.

which action performed by the pt with diabetes would increase the rick of sepsis during foot care? A. cleansing cuts with iodine. B. trimming the nails after shower C. wearing leather shoes while walking D. cutting toenails even with a rounded contour

the pt with diabetes should clean cuts with warm water and mild soap, but not with iodine.

what is the priority during intervention for an older pt with diabetes mellitus who present with a large leg ulcer? A. teaching techniques for dressing changes B. Informing the pt about insurance companies C. Discussing community resources to obtain support D. teaching how to transfer from a bed to chair in the least painful manner

the teaching how to transfer from the bed to chair in the least painful manner. the priority nursing intervention for an older diabetic pt with a large leg ulcer is to teach him/her how to transfer from a bed to a chair in the least painful manner.

while caring for a client with impaired memory and orientation, a nurse notes poor hygiene self-care. the nurse lowers the pt's bed and ensures sufficient night lighting. what is the reason for these nursing interventions? A. to reduce anxiety B. to reduce the sensory stimuli C. to reduce the risk of falls and injuries D. to reduce the incidence of disturbed thought processes

to reduce the risk of falls and injuries (a pt with impaired memory, orientation, and deficits in bathing self-care may have dementia. the nurse should lower the client's bed and ensure sufficient night lighting to help prevent falls and injuries. the pt's safety is also ensured by placing personal articles within the pt's reach.