Exam 2

As part of an assessment the nurse assessed the clients sensory experience. Which question would best assess sensory stimulation?

" Do you feel bored? "

A pediatric clients caregivers states " I will never give my child vaccinates " what is the priority nursing response?

" help me understand your thoughts about vaccinations,"

The oncology nurse is caring for a client receiving chemotherapy which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?"

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

"These barriers help prevent the transmission of infection to you or other people."

The nurse is educating a client with human immunodeficiency virus (HIV) on a new antiviral medication which client statement indicates a need for further teaching?

"This medication will cure me of this virus."

A nurse is assessing clients in a burn unit for sensory alterations which factor contribute to severe sensory alterations? Select all that apply

1) sleep deprivation 2) sensory deprivation 3) sensory overload

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump.

The nurse is caring for a client admitted with tuberculosis (TB) what would be the best action by the nurse?

Apply a nonparticulate (N-95) respirator when entering the room.

Orange too wipes

CDAP

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

normal flora

Microorganisms that reside in or on the body without causing disease

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident what should the nurse do?

Minimize background noises and ensure that lighting is adequate to see the nurse's face.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

A client who blind is said to be experiencing?

Sensory deficit

Every 2 hours the nurse turns and repositions the client who is experiencing frequent diarrhea this action supports among other thing infection prevention which assessment indicates that there is a positive outcome from this nursing care?

Skin is dry and intact

A client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client?

Talk to the client in a normal tone of voice.

Surgical asepsis is defined as

absence of all microorganisms

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

allowing more time for the processing of the information

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

perception

The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing independently drowsy but arousable with extreme or repeated stimuli. How will the nurse document the clients level of consciousness?

stupor

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year old son and has her 2-year old daughter in tow, based on the nurses developmental knowledge of toddlers which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classrooms

Which of the following accurately describes senses by which individuals maintain contact with the external environment? Select all that apply.

vision, hearing, smell, taste

The nurse is caring for a postpartum mother who delivered her second child yesterday . The mother states that hee older child has just been diagnosed with chicken pox she is concerned that her newborn will develop the disease. What is the best response by the nurse ?

" have you had chickenpox?"

A client who comes to the clinic asks the nurse , " somebody told me that stress increases my risk for infection. How does this happen? " which response by the nurse would be most appropriate?

" stress leads to increased secretion of cortisol which suppresses your immune response l"

An older adult client who is in a long-term care facility tells the nurse , " I am not eating that , it is poisoned . " which is the best way for the nurse to address the clients statement?

" what makes you think the food is poisoned?"

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

Which statement should the nurse include in the teaching plan for a family learning about fire safety?

"Most people who die in home fires die from inhalation and not from burns."

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks."

A nurse has implemented numerous practice with the goal of reducing the number and transfer of pathogens which actions are consistent with this goal? Select all that apply

1) cleaner the least soiled areas first and then move to the more soiled ones 2) use personal grooming habits such as shampooing hair often to prevent spreading microorganisms

The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing interventions? Select all that apply

1) facilitating interdepartmental coordination about the transport 2) placing a clean sheet on the stretcher that the client will be transported upon 3) ensuring that the client has a mask on 4) reminding transporter to utilize droplet precautions

When preparing a sterile field, the nurse notes they the battle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline use is sterile?

Discard the bottle and get a new one because the saline has expired

The community health nurse wants to identify clients who have lifestyle factors that may be place them at risk for sensory disturbances which question will the nurse ask?

Do you work around loud noises at work?

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin?

Droplet

A school nurse is conducting a program for the parents about common childhood illness. Which information do parent need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?

Eliminating disturbing odors with adequate ventilation

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing . The adult child tries to calm the client without success. Which short-term restraints should the must use to control the adults movement during the procedure?

Extremely restraint

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

Assessment of a clients temperature reveals hyperpyrexia. The nurse interprets this as indicating that the clients temperatures is most likely

Greater than 40.5c

An experienced nurse is teaching a student nurse about the proper use hand hygiene. Which guideline should the nurse provides to the student l?

Hand hygiene is needed after contact with objects near the client

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid from gram stains then nurse understand that this type of testing is beneficial for which reasons ?

Helps to determine prescribed antibiotic therapy

The nurse conducting a hand hygiene in service determine that the participants need additional education when they star the use of an alcohol- based hand rub is appropriate in which situation?

When hands are visibly soiled

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the clients behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

The nurse is reviewing the plan of care for assigned clients which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

The nurse is meeting an older adult client for the first time in their hospital room. Which of the following interventions should be a priority at this time?

asking if the client uses prescription glasses.

A 17-year old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to

automobile accidents

The nurse is caring for a client with a draining abscess which precautions will the nurse begin?

contact

A client is immobilized following a traumatic amputation of both legs. When planning this clients care the nurse would be alert for which factor that has the potential to contribute to sensory deprivation in this client?

decreased environmental stimuli

A client is refusing to take his prescribed medication. The client states that the government is out to get him and is poisoning all of his medication. The nurse understands that the client is experiencing:

delusion

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

handwashing before leaving the client's room

After cataract surgery the clients home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having a caregiver in the home for the first few days after surgery

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care

The most common infection in children is

respiratory

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

sensory deprivation

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all client care and interaction

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

• inaccurate perception of sights, sounds, tastes, and smells • inability to control direction of thought content • difficulty with memory, problem solving, and task performance

A client is diagnosed with hepatitis C what statement made but the client indicates that further education is required regarding the transmission of the virus ?

" I probably got the virus when I sat on the toilet seat in a dirty bathroom"

A nurse is caring for an older adult client who is expressed concern is caring for an older adult client who has expressed concern around the house which question by the nurse is most appropriate to gain more information related to the clients safety at home?

" have you fallen down at all in the last few months ? "

The lovely high school has been espoused to methicillin-resistant straphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply

1) 20 second hand washing 2) use of hand sanitizer when necessary 3) keep draining wounds covered

A nurse is teaching parents about internet safety for children which actions is a recommended guideline for internet use? Select all that apply

1) Use filtering software to block objectionable information. 2) Investigate any public chat rooms used by the children. 3) Be alert for downloaded files with suffixes that indicate images or pictures.

A nurse is caring for an actively confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints which guidelines for the use of restraints should the nurse follow? Select all that apply

1) alternatives to restraints and less restrictive interventions must have been 2) the clients family must be involved in the decision and care plan 3) the benefit gained from using a restraint must outweigh the known risks for that client

The nurse is preparing to perform hand washing place the following steps in the correct order use all options

1) turn on the faucet and adjust force and temperature of the water 2) wet the hands and wrists 3) apply soap 4) wash the palms and back of the hands for atleast 20 seconds 5) pat the hands dry with a paper towel 5) turn the faucet off with a paper towel

The community health nurse is talking with four clients who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics

Which client will the nurse assess for sensory perceptual alterations?

84-year-old client with four recent driving violations

The nurse is providing safety teaching to the family of an older adult client. Which finding in the clients home will the nurse tech the family to address ?

A hair dryer is placed next to the sink

Which is not a lifespan consideration for sensory perception?

A newborn's sensory perception is very refined.

A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. The clients ammonia level is above normal. Which nursing concern is appropriate for this client?

Active confusion

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulation of a continuing noise often goes unnoticed the ICU explains that this phenomenon is known as

Adaption

The nurse instructor is discussing the relation of early ambulating and infection control. Which response from the student indicates the need for further explanation?

All clients must ambulate as early as possible to avoid infection

A 4-year child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6 to 8 hours per day. Based on this information what nursing concern is applicable to this family?

Altered parenting associated with failure to provide stimuli for growth

The nurse overheard an older adult clients son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers . What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately

Opportunities

Bacteria that normally cause no problem but can be harmful in susceptible people

The nurse is caring for a client that requires a dressing change when applying the principles of asepsis what aspect of care should the nurse include ?

Blood and body fluids are major reservoirs for microorganisms.

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?

Centers for Disease Control and Prevention

The poison control nurse receives a call from the caregivers of a young school- age child who may have ingested a poisonous substance which is the priority response by the nurse?

Check breathing and heart rate ?

The nurse is caring for Janawork, a 23/year old client who suffered a traumatic brain injury in a motor vehicle accident. Jana requires mechanical ventilation, cannot be aroused , and displays no response to painful stimuli. The nurse documents that Jana's level of consciousness is which of the following?

Coma

A confused clients is pulling at the IV line. When considering alternatives to restraints , which nursing interventions would be first?

Conceal IV tubing with gauze wrap

The nurse has completed an intervention with a client there is no visible soling on the nurses hands which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub

A nurse is assessing a clients state of awareness and under the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as

Delirium

A nurse instructor is speaking to a group of nursing students about proper care of the ears to promote hearing as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes

Demonstrating or pantomiming ideas to clients with hearing impairements

The student nurse is preparing a presentation on sensory perception what symptoms of sensory deprivation should the student include? Select all that apply.

Depression Sleeplessness Decreased interest in activities

A nurse is implementing the principles of surgical aspepsis while inserting a clients in dwelling urinary catheter which action should the nurse perform?

Hold sterile objects above waist level to prevent accidental contamination

A nurse visits an adult client at home and assesses the safety of the clients environment multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the clients safety?

I am concerned that the small rugs in your home can be a tripping hazard

To enurse needlesticks as potential hazards to nurses, the nurse should

Immediately deposit uncapped needles into a puncture- proof plastic container

The nurse working with the hospitals infection control team is attempting to decrease the transmission of healthcare - associated pathogens which intervention will be most effective?

Incentivizing health care workers to utilize hand hygiene

Jackson-Pratt

Indicated when tissue trauma may occur with a rigid drain tube (eg. hemovac)

The nurse is receiving a confused client with a draining wound into the medical-surgical unit which took assignment will the nurse make?

Into a private room

A nurse working in a long-term care facility is instituting interventions to prevent falls. Which interventions is an appropriate alternative to the use of restraints for ensuring clients safety and preventing falls?

Involve family members in the clients care

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse including in the teaching?

Keeping medications in clearly labeled containers

A nurse is working with a 55-year old women diagnosed with human immunodeficiency virus (HIV) this nurse had another client that day who has an upper respiratory infection what is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

Left on hand hygiene before and after entering the clients toom

Colonization

Organism resides in the body with no clinical signs of infection

The nurse is teaching the caregiver of an adolescent child about safety which teaching will the nurse include ?

Peer pressure causes children of this age to take risks.

Infection

Persons defense mechanisms are infective in responding to colonization resulting in specific monifestations of diease

The nurse is caring for a client who has active tuberculosis and is under airborne precautions the health care provider prescribes a computed tomography CT examination of the chest which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time.

The nurse is creating a plan of care for an older adult client who takes multiple medications and a has difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing concern to include in this clients plan of care?

Poisoning risk related to poor eyesight and the inability to read medication labels

What is the primary role of the nurse in the care of the clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

A client has been told that he has lung cancer. The health care provider then describes several potential courses of treatment to the client when the health care provider leaves the room, the client asks the nurse, " what did he just say?" The nurse understands that the client is experiencing.

Sensory overload

An intensive care unit (ICU) nurse does notice the noise within the environment . However a clients family member states, " how can you stand it here? The lights , sounds , and activity would've

Sensory overload can cause anxiety and irritability

A father asks the nurse who is caring for his 13-year old daughter why his daughter could be performing poorly in school lately and why she is distancing herself from friends & family and which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying.

A client has an i Guiana hernia repair and later develops a methicillin-resistant staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

Surgical asepsis

The nurse is caring for a client with a cough and copious secretions before producing care , the nurse observes the licensed practical nurse (LPN) standing outside the clients room and donning personal protective equipment as shown above . How should the nurse best interpret the LPNS actions?

The LPN is donning personal protective equipment appropriately

The acute care nurse is caring for a client who is at risk for falling which desired outcome is most appropriate for this client?

The client will not experience a fall and remains free of injury.

A nurse has identified the clients lack of knowledge regarding their prescribed antibiotic therapy. Which outcome is appropriate for the nurse to include in the clients care plan based on this nursing concern?

The client will state how to safety take the prescribed antibiotic

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx an event that the centers for Medicare & implication of this CMS designation?

The hospital must bear any costs incurred for treating the clients injury

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct teetering the filing of a safety even report?

The nurse should record the incident in the clients medical record and fill out a safety event report separately

A nurse is preparing to implement an order for the use of restraints to ensure a clients safety which statement accurately describes a guideline to follow ?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Which client is at greatest risk of sensory overload?

an 88-year-old on a ventilator in an intensive care unit

The nurse is initiating isolation precautions for a client who has chronic clostridium difficile infection what should the nurse be sure to include with these precautions?

be sure that there are gloves of various sizes and gowns for use

A nurse suspects that a client has a respiratory infection which symptom would the nurse be least likely to assess?

clear mucus

The nurse is getting ready to change the clients wound dressing which step best supports infection control?

handwashing

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

impaired memory

What is the second line of defense in microbial invasion?

inflammation

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory.

overload