FUNDAMENTALS QUIZ CH.31-33

Which patients should be monitored with the Mini Mental State Examination? a. Patients with cognitive alterations b. Patients exhibiting signs of depression c. Patients showing loss of motor function d. Patients complaining of auditory changes

ANS: A The Mini Mental State Examination tests the patient's orientation, language ability, spatial orientation, and attention as well as the ability to calculate and recall.

A patient who is trying to lose weight requests information from the nurse to improve sleep patterns. What recommendation would be appropriate for this patient? a. Do not drink diet colas for at least 4 hours prior to bed. b. Increasing evening exercise will increase sleepiness. c. High protein bedtime snacks are appropriate. d. Using diet pills will improve sleep patterns.

a

10. Which intervention would be most appropriate for the nurse to include in the care plan for a patient who is experiencing constipation and increased heart and respiratory rates? a. Time management b. Decreased grain intake c. Relaxation therapy d. Regimented exercise

c

Identify one concern for patients with peripheral neuropathy: a. burns b. dizziness c. confusion d. visual deficits

ANS: A Patients with peripheral neuropathy suffer damage to peripheral nerves, altering the ability to feel extremes of hot and cold. Dizziness can be related to central nervous system disorders or to problems with the inner ear. Confusion is a cognitive deficit. Visual deficits are related to problems with the eye, blood vessels in the eye, or the optic nerve.

The nurse determines that the patient's self-care abilities have declined. What is the nurse's next step? a. Re-evaluate the plan of care. b. Assist the patient with more ADLs. c. Assess the patient's sensory pathways. d. Delegate more responsibility to assistive personnel.

ANS: A The plan of care is re-evaluated on an ongoing basis. Whenever a patient goal is not met, changes in the plan of care may be necessary. Evaluation takes place before new interventions or delegation occur.

Which part of patient care of the cognitively impaired patient can be delegated to assistive personnel? (Select all that apply.) a. Assistance with hygiene and ambulation b. Re-orienting the patient to time and place c. Assessment of cognition and mental status d. Turning and toileting the patient every two hours e. Evaluating the effects of nursing interventions on the patient

ANS: A, B, D The nurse can delegate routine, repetitive care to assistive personnel. Assessment, planning, and evaluating require critical thinking by the nurse and are therefore not delegated.

Which nursing interventions should be used if a patient is discovered to be hard of hearing upon initial assessment? (Select all that apply.) a. Providing written instructions for the patient b. Standing beside the patient when speaking c. Enabling closed captioning on the television d. Speaking into the ear on the side with weaker hearing

ANS: A, C Written instructions and closed captioning allow the patient to see words. Standing in from of the patient so lips can be seen is recommended. Speaking in the ear with stronger hearing will increase the likelihood of the patient hearing what is said.

Which area of the brain is involved if a patient is unable to distinguish the shape of an object? a. Frontal lobes b. Parietal lobes c. Temporal lobes d. Occipital lobes

ANS: B The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The frontal lobes are responsible for voluntary motor function, concentration, communication, decision making, and personality. The temporal lobes are concerned with hearing and smell. The occipital lobes process visual information.

Which hospitalized patient is most likely to suffer from sensory deprivation? a. An ICU patient on a ventilator b. A bedridden patient with MRSA c. An ambulatory postoperative patient d. A patient admitted for diabetes management

ANS: B The patient with MRSA would be in contact isolation. Immobility and isolation would prevent this patient from a lot of outside interaction, possibly leading to sensory deprivation. An ICU patient is prone to sensory overload. The ambulatory patient and diabetes patient have the potential to interact with the environment.

What is an appropriate nursing intervention for a patient with expressive aphasia? a. Direct questions to family members since the patient cannot speak. b. Make factual statements rather than asking questions. c. Stand in front of the patient and speak loudly. d. Use questions with "yes" and "no" answers.

ANS: D Patients with expressive aphasia are able to comprehend but cannot express themselves. Use of questions with simple answers helps to involve them in care without increasing frustration. Patients should be included in conversations when the ability to understand is present. Questions and statements are directed to the patient. Speaking loudly will increase the patient's frustration since he or she can hear and understand the spoken word.

In a patient with gustatory alterations, which nursing intervention is appropriate? a. Removal of cerumen b. Dimming bright lights c. Turning every two hours d. Oral hygiene twice daily

ANS: D Patients with gustatory alterations have problems with taste. Removal of cerumen improves conductive hearing. Keeping the mouth clean and fresh has a positive impact on taste. Dimming bright lights helps decrease sensory overload. Turning every 2 hours prevents pressure ulcers.

Which family statement indicates understanding of teaching regarding presbycusis? a. "I should change positions quickly to stabilize the inner ear." b. "There are no precautions if I take motion sickness medications." c. "I should play soft music to distribute vestibular sound." d. "My family should speak clearly and distinctly."

ANS: D The patient with presbycusis has hearing loss and should be spoken to clearly and distinctly. Position changes will not affect the hearing loss. Soft music will not be heard by patients with hearing loss and has no advantages. Patients taking motion sickness medication should refrain from driving.

When caring for an elderly patient who presents with acute confusion of sudden onset, which test would the nurse expect to be ordered? a. Urine culture and sensitivity testing b. Mini-Mental State Examination c. Swallow evaluation d. MRI with contrast

Answer: a A major cause of acute confusion in the elderly is infections including urinary tract infections and pneumonia. Urine culture and sensitivity testing will detect bacteria in the urine and determine proper antibiotic treatment. A Mini-Mental State Exam is a valuable tool to assess the progression of dementia. Swallow evaluation is done in patients who are suspected of having a weak or absent gag reflex. MRI with contrast might be done in a patient with confusion after infection has been ruled out.

Which nursing intervention is appropriate for a patient with sensory overload? a. Dimming the lights b. Performing care a little at a time c. Leaving the patient's door open d. Rushing to get care done quickly

Answer: a Dimming the lights decreases sensory stimuli which alleviates sensory overload. Constant disruption adds to the overload, as does leaving the door open and rushing while in the room. A calm, quiet atmosphere diminishes the overload.

When caring for a hearing impaired patient, use of which technique by the nurse would facilitate communication? a. Speaking clearly with distinct words b. Talking slowly to facilitate understanding c. Sitting behind the patient to decrease distractions d. Standing near the patient's affected ear to balance sound

Answer: a Speaking clearly without shouting facilitates communication with the hearing-impaired patient by giving each word separate emphasis. Talking distinctly, but not too slowly, and allowing the patient to see facial expressions and read lips, with the use of hearing aids if prescribed, are good communication techniques. Speaking into ear with the better hearing is recommended.

Which statement by the patient with vertigo lets the nurse know that the patient has understood the home-going instructions? a. "I will buy a visual signal for my smoke detectors." b. "I will have grab bars installed in my bathtub." c. "I will change positions quickly to avoid vertigo." d. "I will get a home phone with amplified sound."

Answer: b Grab bars provide stability for the patient with vertigo. Patients with vertigo should change positions slowly to avoid worsening of the spinning sensation. Visual signals and amplified sound are used in the home of the patient with hearing deficits.

A visually impaired diabetic patient states that he has lost the call light. What is the next step the nurse should take? a. Clip the call light closer to the patient. b. Tell the patient that the call light is clipped to the bed. c. Describe the call light location, and take the patient's hand and guide it to that location. d. Instruct the patient to verbally call for a staff member because "someone is always nearby."

Answer: c Always leave the call light within easy reach of the patient. Use of the patient's senses of both touch and hearing enables the patient to locate the call light easier. Simply telling the patient that the call light is clipped to the bed is not adequate, because the patient will not know where on the bed to look. Verbally calling for the nurse is not acceptable because the nurse and other staff members might be out of hearing range.

Which goal statement is appropriate for a patient with the nursing diagnosis of Impaired Memory? a. Patient will remember nurse's name. b. Nurse will remind patient of his or her name each shift. c. Patient will state name and date with each nursing encounter. d. Nurse will remind patient of name and date with each nursing encounter.

Answer: c Goals are always patient-centered and measurable and have a specified time frame. A patient goal would not include a nursing behavior. A confused patient would not be expected to remember different nurses' names but would be assessed for person, place, and time orientation with each encounter.

Which nursing diagnosis is most appropriate for a patient with presbycusis? a. Impaired Verbal Communication b. Disturbed Thought Processes c. Disturbed Sensory Perception d. Impaired Physical Mobility

Answer: c Presbycusis is age-related hearing loss. The nursing diagnosis of Disturbed Sensory Perception is appropriate for patients with visual, auditory, kinesthetic, gustatory, tactile, or olfactory deficits. Impaired Verbal Communication relates to the ability to speak and form words. Disturbed Thought Processes is appropriate for patients with cognitive deficits. Patients with limitations of movement may have a nursing diagnosis of Impaired Physical Mobility.

The nurse is caring for a patient with decreased sensation in the lower extremities. Which precaution does the nurse advise the patient to take? a. Use heat to warm hands during cold weather. b. Go barefoot at home to prevent blisters from shoes. c. Soak feet in cold water daily to decrease swelling. d. Test the bath water temperature to prevent burning injuries.

Answer: d Because the patient may not be able to feel the temperature of the water, using a thermometer will prevent burns. The use of heat and cold is contraindicated in patients with tactile deficits because they would not be able to feel if the therapy was too hot or cold. The patient should wear good-fitting shoes around the house to prevent foot injury.

Which recommendation in the home-going instructions is appropriate for a patient with damage to the chemoreceptors of the upper nasal passages? a. Arranging for lighted signals on doorbells and telephones b. Obtaining a thermometer for testing bath water temperature c. Installing amplification devices on televisions, doorbells, and telephones d. Scheduling yearly safety checks of gas, hot water heaters, and furnaces

Answer: d Patients with damage to the chemoreceptors of the nasal passages may not be able to smell noxious fumes from household appliances. Lighted signals and amplification are interventions for a person with auditory deficits. Testing the bath water temperature is important for patients with tactile deficits.

Which nursing interventions would be necessary in caring for a patient with cognitive alterations who is hospitalized? (Select all that apply.) a. Apply wrist restraints for combativeness. b. Place a clock in the room for orientation. c. Keep floor free of clutter for safety. d. Identify staff with each interaction. e. Play loud music for distraction.

Answers: b, c, d Reality orientation is important for patients with cognitive alterations. Keeping the floor free of clutter prevents falls. All staff members should wear a readily visible name tag and state their name and what they are going to do. Soft music and dim lights will create a less distracting environment for the patient. Restraints may cause increased confusion and agitation and are used in special circumstances only.

1. Stress may be referred to as positive or negative.

T

2. The physiologic response to stress is a. activation of the autonomic nervous system with increased heart rate and respirations. b. activation of the parasympathetic nervous system with relaxation of smooth muscle and decreased secretions. c. activation of the autonomic nervous system with peripheral vasodilation, decreased blood pressure, and pupil constriction. d. activation of the parasympathetic nervous system with increased gastric emptying, dry mouth, and adrenal suppression.

a

3. The stages of Selye's General Adaptation Response are a. alarm, resistance, and exhaustion. b. excitement, adaptation, and coping. c. activation, coping, and adaptation. d. appraisal, reaction, and resolution.

a

7. The patient has just been told that he has cancer. When the nurse assesses the patient at shift change, his heart rate and respirations are elevated. What type of response is this to stress? a. Physiologic b. Psychological c. Somatic d. Neurologic

a

9. Which short-term goal would be most appropriate for a patient with the nursing diagnosis Anxiety related to upcoming diagnostic tests, as evidenced by expressions of concern and pacing around the room? a. Patient will discuss specific aspects of concern. b. Nurse will administer prescribed antianxiety medication. c. Patient will understand diagnostic test procedures. d. Nurse will describe test procedures in detail to allay concerns.

a

A male patient is told that he may have colon cancer. Which response by the patient best indicates that his initial appraisal of the situation is primarily a challenge to be met? a. Requesting information on various treatment options b. Demanding to see another physician immediately c. Storming out of the gastroenterologist's office d. Yelling at the nurse who is scheduling his colonoscopy

a

A mother brings her toddler for a well-child checkup and mentions that she is having a lot of trouble getting the child to go to bed. Which intervention can the nurse teach the mother to help her toddler establish good sleep habits? a. Establish and maintain a consistent bedtime routine. b. Put the child to bed immediately after the evening meal. c. Allow the child to stay up as long as desired to increase sleepiness. d. Allow the child to sleep with the parents until the child is older.

a

A nurse is completing discharge planning for a new mother and newborn infant. Which statement by the mother indicates an understanding of infant care? a. "Sleep patterns of a newborn are irregular." b. "I will put a small pillow and bumpers in the crib." c. "My baby should sleep through the night within a week." d. "Babies sleep best when placed on their stomach."

a

A nurse who was hired to work in a sleep lab understands that the most common type of sleep apnea is caused by which factor? a. Airway collapse b. Lack of exercise c. Dietary factors d. Medication use

a

A patient has been diagnosed with obstructive sleep apnea. What teaching regarding a common intervention for this disorder is the nurse likely to initiate? a. The proper use of devices to support the patency of the airway b. The correct administration of sleeping medications c. The use of a supine position for sleeping d. The use of caffeine to maintain alertness

a

A summer camp nurse is prescreening a school-age child who has a diagnosis of sleep enuresis. What intervention does the nurse expect the child to request while at camp? a. Separate sleeping area to use a bed alarm b. Separate sleeping area close to the bathroom c. Separate sleeping area for a later bedtime d. Separate sleep area with access to bedtime snacks

a

Two adult siblings are caring for their ill mother, who requires 24-hour care. She needs assistance with feeding, bathing, and toileting. One of the siblings takes time to exercise after work, whereas the other goes directly to the mother's home before and after work each day. The nurse recognizes that people may react differently to the same stressors depending on which factors? (Select all that apply.) a. Individual coping skills b. Type of identified stressor c. Amount of perceived stress d. Personal appraisal of the stressor e. Hair color, gender, and skin type

a, b, c, d

Which statement by a patient would indicate the use of effective coping strategies? (Select all that apply.) a. "Each month, my wife and I attend a support group for parents of children with autism." b. "Talking with my spiritual adviser may challenge my thinking on how best to handle this situation." c. "I've invited my son to join me for drinks at the bar each night on his way home from work so we can spend more time together." d. "We are looking into joining the new health club facility in our neighborhood." e. "After working all day, I eat dinner in front of the television while my family sits at the kitchen table."

a, b, d

The nurse is completing a sleep assessment for a newly admitted patient. Which data reported by the patient would cause the nurse to suspect obstructive sleep apnea? (Select all that apply.) a. Morning headaches b. Sudden weight loss c. Loud snoring during sleep d. Daytime sleepiness e. Deep sleep during the night f. Increased blood pressure problems

a, c, d, f

An elderly, tense patient is having trouble relaxing enough to sleep. Which measures should be implemented by the nurse to help promote sleep? (Select all that apply.) a. Give the patient a back rub. b. Take the patient for a brisk walk right before bedtime. c. Provide a warm, quiet environment. d. Encourage the patient to eat a large meal in the evening. e. Give the patient a diet cola. f. Play soft music during the 30 minutes before bedtime.

a, c, f

1. There is great variation among individual responses to the same stressor. In addition to age, nutritional status, and genetic inheritance, which additional factor influences the expression of stress response and reflects the complex psychological processing involved? a. The amount of stress b. The individual's appraisal of the stressor c. The context of the stressful event d. The type of stressor

b

A nurse is working a night shift after several months of working day shift. What action does the nurse take to protect patient safety? a. Take a meal break at midnight. b. Plan critical tasks for early in the shift. c. Ask another nurse to administer all medications. d. Turn up lights on the unit to maintain alertness.

b

A parent is the primary caregiver for a child with multiple disabilities requiring constant care. The parent reports sleeping in 45 minute blocks during the night, having trouble concentrating, and being increasingly irritable. The nurse recognizes that this parent is consistently missing what stage of sleep? a. Nonrapid eye movement (NREM) stage 2 b. Rapid eye movement (REM) stage c. Sleep latency stage d. Sleep arousal stage

b

A patient is newly diagnosed with diabetes and requires insulin injections. He requests information about classes offered by the diabetes educator. Which type of coping technique is this patient using? a. Emotion-focused b. Problem-focused c. Avoidance d. Denial

b

An elderly patient complains of difficulty sleeping after the death of his spouse of 56 years. What would be an appropriate nursing assessment for this patient? a. Assess the patient for possible use of sedatives. b. Obtain a health history regarding sleep hygiene. c. Assess the patient's weight over the past year. d. Request a sleep study to rule out sleep apnea.

b

The nurse has been assigned the same patients for the past 4 days. Two of the patients demand a great deal of attention, and the nurse feels anxious and angry about being given this assignment again. What action would demonstrate the most effective way for the nurse to cope with the patient care assignment? a. Share complaints about the assignment with the nurse manager. b. Prioritize the patients' needs, and identify a specific time period for care for each patient. c. Talk with the patients, and explain that they cannot expect so much personal attention. d. Trade assignments with another nurse who is unaware of the concerns regarding the patient assignment.

b

The nurse knows that a desired outcome for a sleep-deprived patient has been met when the patient makes which comment? a. "I have less of a headache every morning." b. "I have enough energy to do my housework every day." c. "I only get up three times during the night to go to the bathroom." d. "I only smoke one pack of cigarettes per day now."

b

A patient reports that the prescribed sleeping medication is no longer effective. What information would be appropriate for the nurse to recommend to the patient? (Select all that apply.) a. Take the medication with an alcoholic drink. b. Use relaxation techniques before sleep. c. Do not study in the bedroom before bedtime. d. Adjust sleep temperature for comfort. e. Sleep in a different room of the home.

b, c, d

4. Successful coping is thought to involve a. problem-focused efforts. b. emotion-focused efforts. c. both problem-focused efforts and emotion-focused efforts. d. physiologic efforts.

c

5. The hormone used as a physiologic marker for stress is a. ACTH. b. ADH. c. cortisol. d. Aldactone.

c

8. George is a junior college student. Recently he has felt anxious and jittery. He decides that he will swim during his lunch hour. After several days he notices a decrease in feeling anxious. What type of stress management did George use? a. Guided imagery b. Biofeedback c. Exercise d. Progressive muscle relaxation

c

A patient admitted to the hospital complains of sharp, tingling sensations in his lower extremities that prevent him from sleeping. The nurse suspects the patient may have which sleep disorder? a. Obstructive sleep apnea b. Narcolepsy c. Restless leg syndrome d. Insomnia

c

A patient complains of not being able to sleep while in the hospital. What action would be a priority for the nurse to implement? a. Administer a sleeping medication with the evening meal. b. Restrict visitors for the patient in the evening. c. Decrease noise around the patient during the night. d. Offer a hot drink of regular tea at bedtime.

c

A patient reports using a combination of prescription sleeping medication and alcohol every night for the past 8 months after the loss of her job. She tells the nurse that she now wants to stop taking the sleeping medications. What teaching would be appropriate for the nurse to provide? a. The same sleep routine should be followed until the patient finds another job. b. An additional prescription medication will be needed. c. The medication should not be stopped suddenly. d. Diet changes will be needed before stopping the medication.

c

Which lifestyle changes should the nurse recommend to a patient with recent onset of insomnia related to a job change? a. Obtain a prescription for sleep medication. b. Increase evening alcohol intake to induce relaxation. c. Arise each day at the same time. d. Increase evening exercise to promote sleepiness.

c

4. When using a stress assessment tool with a patient from another culture, what factor(s) must the nurse take into consideration? (Select all that apply.) a. Specific methods of managing stress are revealed in using stress assessment tools. b. Stress assessment tools should be used only for persons living in North America. c. Stress assessment tools may not be appropriate for all people of all ages. d. Resistance resources become evident when stress assessment tools are analyzed. e. Adaptations may need to be made to the assessment tool based on circumstances

c, e

6. The term McEwan used to describe the burden of prolonged stress is a. homeostasis. b. distress. c. "fight or flight." d. allostatic load.

d

A 25-year-old female patient demands that her mother or father be present during all blood testing. Which defense mechanism could the nurse document as being used by this patient? a. Sublimation b. Repression c. Projection d. Regression

d

A patient has been referred for polysomnography to confirm a diagnosis of narcolepsy. What behavior would the nurse expect the patient to be exhibiting? a. Excessive use of sleeping medications b. A lack of dreaming during sleep c. Consistent use of relaxation techniques d. Unexpected daytime sleeping episodes

d

A patient returns to the clinic requesting an increase in prescribed sleeping medication. What teaching should the nurse provide regarding the long-term use of sleeping medications? a. "Long-term use of sleeping medications is an appropriate treatment." b. "Adding diet changes will increase the effects of the medication." c. "More medication will cause hallucinations." d. "Long-term use of sleeping medications can increase sleep disorders."

d

At a routine clinic visit, an athlete training for a major sports event reports difficulty sleeping that is affecting the training schedule. What would be the best recommendation by the nurse for this patient? a. Increase the use of electrolyte-enriched drinks to increase stamina. b. Obtain a short-term prescription for sleeping medications. c. Plan to arise later in the morning to accommodate sleep changes. d. Avoid vigorous exercise for at least 2 hours before bedtime.

d

In the immediate postoperative period after open-heart surgery, a patient who is not a diabetic has elevated blood glucose levels. What physiologic stress response best describes the rationale for the patient's increased blood sugar? a. Release of epinephrine b. Secretion of CRH c. Circulation of endorphins d. Increase in corticosteroids

d