N356 Final

What is cultural relativism?

"ethical theory that moral evaluation is rooted in and cannot by separated from the experience, beliefs, and behaviors of a particular culture, and hence, that what is wrong in one culture may not be so in another"

What is ethical subjectivism?

"individuals create their own morality and there are no objective moral truths - only individual opinions" people's beliefs about actions being right or wrong depend on how other people feel about those actions

What are the elements of affective learning?

(from bottom to top) -receiving -responding -valuing -organization -internalizing values

What elements does cognitive learning include?

(from simple to complex/concrete to abstract) -remembering -understanding -applying -analyzing -evaluating -creating

What are some disparities do LGBTQ individuals face with sexuality?

-2-3x more likely to attempt suicide -more likely to be homeless -less likely to receive preventative services for cancer -gay men are at higher risk for HIV and other STDs -and many more!

Complications of Wound Healing: Infection

-2nd most common HCAI -purulent drainage or positive culture -signs: fever, erythema, increased drainage, tenderness, pain, elevated WBC

Who does Medicare cover?

-65+ -disability

What factors affect sensation?

-Age -Meaningful stimuli -Amount of stimuli -Social interaction -Environmental factors -Cultural factors

What are key ways to prevent acute pain?

-Astute pain assessment -An understanding of effective treatments for acute pain and evidence-based pain care -Patient advocacy -Involvement of patients and families in decisions surrounding pain care

Patients at risk for pressure ulcers

-Bed rest patients -Incontinent patients -Diabetic patients -Paralyzed patients -Cachectic patients -Obese patients -Older adults that have experienced trauma -Those with spinal cord injuries -Those with hip fractures -Those in LTCs -Those in critical care -Neonates -Those >65YO

How does carbon dioxide transport work?

-CO2 diffuses into RBCs and is rapidly hydrated into H2CO3 -H2CO3 then dissociates into hydrogen and HCO3- ions -Hemoglobin buffers hydrogen ions and HCO3- diffuses into the plasma

Examples of HCAIs

-Catheter-associated urinary tract infection (CAUTI) -Central line-associated blood stream infection (CLABSI) -Surgical site infection (SSI) -Clostridium difficile (C. diff) -Methicillin-resistant staphylococcus aureus (MRSA)

What are the different types of complicated grief?

-Chronic grief: grief reactions that do not subside but continue over a long period of time -Masked grief: survivor is unaware that behaviors are interfering with normal functioning as a result of loss -Delayed grief: reactions are suppressed or postpones; survivor is consciously or unconsciously avoiding the pain of the loss

Heart Sounds: S2

-Closure of aortic/pulmonic valves -Beginning of diastole -"Dub"

Heart Sounds: S1

-Closure of mitral/tricuspid valves -Beginning of systole -"Lub"

What are holistic health models?

-Considers emotional and spiritual well-being as important aspects of physical health and wellness -Recognizes natural abilities of the body and incorporates complementary and alternative modes of healing

What is orthostatic hypotension?

-Decrease in systolic BP by 20 mmHg -Decrease in diastolic BP by 10 mmHg -Happens within 3 minutes of standing from sitting or supine

Mobility: Metabolism and GI Changes

-Decreased BMR -Fluid and electrolyte imbalances -Decreased calories and protein -Negative nitrogen imbalance -Calcium resorption increases -Reduced motility in GI tract

How does sleep deprivation affect the body?

-Decreased melatonin --> cancer -Reduction of stress hormone that increases BP --> heart disease -Difficulty regulating blood sugar --> diabetes -Disruption of hormones that regulate appetite --> obesity -General changes in immune function

What is Parenteral Nutrition?

-Delivery of food intravenously -CVN: central venous nutrition -PPN: peripheral parenteral nutrition -Involves lipids and fat emulsions -Requires weaning

What is Enteral Nutrition?

-Delivery of food through a tube into the stomach or the GI -Preferred method/route (keeps gut working) -EX: nasogastric, orogastric, jejunal, gastric

What are some signs of grief in older children?

-Difficulty concentrating -Forgetfulness -Poor schoolwork -Insomnia or hypersomnia -Social withdrawal -Resentment of authority -Overdependence and regression -Resistance to discipline -Running away from home -Talk of (or attempted) suicide -Nightmares and symbolic dreams -Frequent sickness -Accident proneness -Over- or under-eating -Truancy -Experimentation with drugs or alcohol -Sexual promiscuity

What are examples of nonpharmacologic pain interventions, specifically psychological modalities?

-Distraction -Guided/controlled breathing -Mindfulness -Active listening -Education -Dec. stimulation -Psychotherapy -Biofeedback

Components of Nutrition Interventions

-Education -Adaptive measurements -Interdisciplinary care -Physiologic changes -Individualized planning

2 Main Types of Therapeutic Diets

-Enteral nutrition -Parenteral nutrition

What factors are needed for integrative nursing?

-Environment -Health -Relationships -Security -Purpose -Community

Extrinsic Risk Factors for Falls

-Environmental hazards outside and within the home -Inappropriate footwear -Unfamiliar environment -Improper use of assistive devices

What are examples of groups that pass administrative/regulatory laws?

-FDA -State boards of nursing

What pain scale(s) is/are BEST to use with cognitively impaired older adults?

-Faces -Numeric rating -Verbal descriptor

What are the 3 developmental theories?

-Freud's psychoanalytical model -Erikson's theory of psychosocial development -Piaget's theory of cognitive development

Pressure Ulcer: Stage 4

-Full thickness tissue loss with exposed bone, tendon, or muscle; extensive destruction -possible slough or eschar -often undermining and tunneling -depth varies on location

Pressure Ulcer: Stage 3

-Full-thickness skin loss extending into the subcutaneous tissue -May see subcutaneous fat but not muscle, bone, or tendon -sloughing may be present -depth varies by location -Eschar may be present -possible undermining and tunneling

What is the difference between grieving and suffering?

-Grieving is the process of working through losses -Suffering is the measure of the gap between reality and what is desired

Mobility: Respiratory Interventions

-HOB up while on bed rest -frequent turning (every 2 hours) -cough and deep breathing -incentive spirometer (10 times/hour) -chest physiotherapy -avoid dehydration -nasotracheal or orotracheal suctioning (last resort)

Types of Physical Assessment

-Head to toe (comprehensive) -Shift assessment (focused) -Area of concern (very focused) -Specialty (focused) -Unstable (on an unstable patient)

What are the 4 models of health and illness?

-Health belief model -Health promotion model -Holistic health models -Maslow's hierarchy of needs

What are some "normal" physical grief reactions?

-Heart palpitations -Breathlessness -Headache, dizziness -Increase or loss of appetite -Chills -Fatigue -Sleep disturbances -Numbness or tingling -Easily startled -Nausea, Upset stomach -Tremors, shakes -Sweating -Muscle weakness -Pain in chest (needs to be checked by health care practitioner) -Tightness in throat -Lack of coordination

Mobility: Metabolism and GI Interventions

-High protein diet -Maintain adequate hydration -Meticulous mouth care -Stool softeners, laxatives, fiber supplements -Bedside commode -Monitor labs -Have family bring food if appropriate

Intrinsic Risk Factors for Falls

-History of a previous fall -Impaired vision -Postural hypotension or syncope -Conditions affecting mobility -Conditions affecting balance and gait -Alterations in bladder function -Cognitive impairment -Adverse medication reactions -Slowed reaction times -Deconditioning

Evaluation of Nutrition

-How much of meal patient consumed (%) -Measurements -Labs

What is Maslow's hierarchy of needs?

-Humans all have the same basic needs -Extent which people meet their basic needs is a major factor in determining level of health Factors (bottom to top): -Physiological needs -Safety and security -Love and belonging -Self-esteem -Self-actualization

Factors that increase blood pressure

-Increased cardiac output -Increased peripheral resistance -Increased blood volume -Increased hematocrit (decreased blood flow) -Decreased elasticity

What are examples of nonpharmacologic pain interventions, specifically physical modalities?

-Massage -Heat -Cold -Repositioning -Pet therapy Hydrotherapy -Ultrasound -Exercise programs

Components of Medical Nutrition Therapy (MNT)

-Metabolize -Correct -Eliminate

What are some signs of grief in younger children?

-Nervousness -Uncontrolled rages -Frequent sickness -Accident proneness -Antisocial behavior -Rebellious behavior -Nightmares -Depression -Excessive dependency

What is irritant contact dermatitis?

-Non-immunologic inflammation of the skin -Causes: Detergent, Soap, Perfume, Latex -Can occur within a few hours of soiling -Tender and painful -Crusting of skin may be present

How should incidents be documented in the medical record?

-Objectively document what was seen -Document what the patient and family said, using quotes if possible -Document assessment finding -Document who was notified -Document disclosure to patient and family per facility protocol, including who was present and what facts were presented -Document follow-up treatment and responses to treatment

Mobility: Cardiovascular Changes

-Orthostatic hypotension -increased workload due to decrease in venous return to heart -Risk for DVT

Pressure Ulcer: Stage 2

-Partial thickness (some skin loss or blistering) -shallow, open ulcer -no bruising

What is the health promotion model?

-Pender (1982) -Complements health protection -Health: "positive, dynamic state, not merely absence of disease" Factors -Individual characteristics and experiences -Behavior-specific knowledge and affect -Behavioral outcomes in which the patient commits to or changes a behavior

What is the PLISSIT Model of Sex Therapy?

-Permission -Limited Information -Specific Suggestions -Intensive Therapy

What are some sources of hospital expenses?

-Personnel (59%) -Other supplies and services (23%) -Capital expenses (7%) -Prescription drugs (6%) -Other operating expenses (5%)

Components of Nutrition Assessment

-Physical signs -Diet history -Measurements -Self-care abilities -Dietary education -Physical environment -General eating patterns

Nursing Priorities with Nutrition

-Promote optimum nutrition -Teamwork and collaboration -Patient/family involvement

What is the health belief model?

-Rosenstoch (1974) and Becker & Maiman (1975) -Relationship between beliefs and behaviors -Perception of susceptibility of illness -Individual's perception of seriousness of illness -Likelihood that a person will take preventative actions Factors -Individual perceptions -Modifying factors -Likelihood of action

Active Listening Components

-S: sit slightly forward -O: open, relaxed posture -L: look into eyes -A: attention to others -R: reflect

What are some signs of complicated grief?

-Severe social withdrawal -Violent behavior -Suicidal ideation -Workaholic behavior -Severe deterioration of functional status -Loss of interest in health or personal care -Signs of PTSD -Severe depression -Severe impairment in communication, thought processes, or motor skills -Extreme denial -Ongoing insomnia or loss of appetite -Replacing loss quickly -Searching or calling out for deceased -Avoiding reminders -Imitating the deceased

Treatment of UTIs

-Symptom control (Pyridium to decrease burning) -Hydration: >2L/day -Antibiotics for 7-10 days -Decrease bladder irritants (caffeine, alcohol)

Explain how the sleep cycle works.

-Typically have 4 to 8 cycles a night with an increase in REM each time -NREM 1-4, then 4-2, then ends with period of REM sleep

What nursing handover styles exist?

-Verbal handovers: when nurses talk to each other -Nurse reads the patient's medical notes -Combo. of verbal and reading -Done at bedside so patient can contribute

What is sleep apnea?

-a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings -also characterized by excessive daytime sleepiness (EDS) 5 episodes of not breathing for 10 seconds in one hour

What is delirium?

-acute confusional state that may be reversible -typically physiologic cause -can present as symptom of systemic infection (often first symptom of pneumonia or UTI) -sudden onset of change in LOC -increased risk for further functional decline -dementia is a risk factor for delirium LIFE-THREATENING MEDICAL EMERGENCY REQUIRES IMMEDIATE INTERVENTION

Mobility: Urinary Interventions

-adequate hydration -bedside commode or urinal nearby -limit catherization GOAL IS TO GET UP TO VOID

Risk factors for wounds

-age -medications -dehydration -malnourished -reduced mobility -impaired circulation -decreased sensation

What are the 3 things that influence the capacity of blood to carry oxygen?

-amount of dissolved oxygen in plasma -amount of hemoglobin -ability of hemoglobin to bind with oxygen

When is it appropriate to use SBAR?

-any situation that requires immediate attention -patient handoffs -progress notes

Techniques that hinder communication

-asking too many questions -using too many "why" questions -stereotyping -offering advice -self-focusing -changing subject EX: Everyone dies eventually so don't worry too much about it

What are the core functions of public health?

-assessment -policy development -assurance

What is normative ethics?

-attempt to decide or prescribe values, behaviors, and ways of being that are right or wrong -focuses of how humans should behave, what should be done in certain situations, what type of character someone should have, and how someone should be

What are the 6 moral/ethical principles?

-autonomy -beneficence -non-maleficence -fidelity -justice -veracity

What does the scope of healthcare economics include?

-availability of resources -utilization of resources -healthcare financing

What is NREM sleep?

-biological functions slow -HR falls, which benefits cardiac function -respirations, BP, and muscle tone decrease -BMR lowers, which conserves body's energy supply -75-80% of sleep time is spent in this stage

What is cyanosis?

-blue discoloration of the skin and mucous membranes -late sign of hypoxia

What is REM sleep?

-brain restoration occurs -associated with changes in cerebral blood flow -increased cortical activity -increased O2 consumption -helps with memory storage and learning -increases with each cycle (ideally)

What is casuistry?

-case-based reasoning -does not focus on rules or theories, but practical decision-making -may compare to previous cases -may be combined with other models/theories

Types of Urinary Incontinence: Reflex

-cause is specific to spinal injury -symptoms: unaware of fullness

What is pulmonary circulation?

-circulation between heart and lungs -moves blood to and from the alveolar capillary membrane for gas exchange

What is medical asepsis?

-clean technique -decrease number of organisms -hand hygiene -standard precautions -gloves, gowns -what we do at home

Examples of Therapeutic Diets

-clear liquid -full liquid -pureed -high fiber -low sodium -low cholesterol -diabetic -mechanical soft

What are the 3 domains of learning?

-cognitive -affective -psychomotor

Mobility: Psychosocial Interventions

-communication -emotional support -activities/diversions -involve family -promote the idea that self care is possible (ensure assistive devices are within reach) EMPHASIZE SAFETY AND INDEPENDENCE

What are the 4 values of Tucson Medical Center?

-compassion -dedication -community -integrity

What are "standards of nursing practice"

-competency level of nursing care -nursing process

Isolation Precautions: Tier Two - Droplet

-coughing, sneezing, speaking, breathing -does not stay in air very long (3-6 feet) -direct: droplets come in contact with mucous membranes -indirect: droplets land on surface, and you touch/spread -EX: strep, rubella, pertussis, influenza, cold, pneumonia Details -private room or with patient with same diagnosis, mask

What are the aspects of professional communication?

-courtesy -use of names -trustworthiness -autonomy and responsibility -assertiveness

Types of workplace violence

-criminal intent -client on worker -worker on worker -personal relationship

Geriatrics: Neurological Changes

-decrease in number and size of neurons -reflexes slow -decreased ability to respond to multiple stimuli -alterations in sleep

Geriatrics: Integumentary Changes

-decrease in skin resilience, elasticity, and moisture -"age spots" -increased risk for breakdowns and tears -assess for skin cancer

Geriatrics: Cardiac Changes

-decreased contractile strength (leads to decreased cardiac output) -HR increases to try to compensate -takes longer for heart to return to baseline -weaker pulses (mainly in lower extremities) -HTN is more common

Geriatrics: Pulmonary Changes

-decreased respiratory strength and lung expansion -less able to cough deeply -calcifications decrease rib mobility -increased chance of pneumonia and respiratory infections

What is criminal law?

-defines crimes and punishment -criminal process (indicted, grand jury, arraignment, discovery, pre-trial motions, trial) -criminal claims must be proven beyond a reasonable doubt -burden of proof is with the state to prove the defendant is guilty Felonies: often jail time Misdemeanors: often fines

What is the Nurse Practice Act?

-defines scope of nursing practice -regulates practice and education institutions -state-level -creates and empowers a board of nursing to carry out all actions -identifies grounds for disciplinary actions -establishes requirements for entry into practice and continual practice

What teaching methods are used to psychomotor learning?

-demonstration -practice -return demonstration -games

What are the models/theories of ethical reasoning?

-deontological -teleological -utilitarianism/consequentialism -feminist ethics -principalism -situational -casuistry

Pressure Ulcer Development: Tissue Tolerance

-depends on integrity of tissue and supporting structures -the greater the degree of shear, friction, and moisture, the more susceptible the skin is -Nutrition, aging, hydration, and BP all affect tolerance

Mobility: Psychosocial Changes

-depression due to dependence -sleep-wake disturbance Developmental Changes -children: stifles emotional and physical growth -older adults: despair, hopelessness

Pressure Ulcer: Unstageable

-depth unknown -completely obscured by slough or eschar

What is insomnia?

-difficulty falling or staying asleep -premature waking -most common in women

Signs and Symptoms of Dementia

-diminished judgement -difficulty articulating words -personality changes -inappropriate affect

Symptoms of urinary retention

-distended bladder -post-void residual >100 mL

What is abdominal percussion commonly used for?

-distension -ascites -abdominal masses

If lymph nodes are enlarged, what should you check for?

-drainage -location -size -assess for underlying causes

What is fidelity?

-duty to be faithful to commitments -confidentiality and privacy are important

What is non-maleficence?

-duty to prevent or avoid doing harm whether intentional or unintentional -harm can occur by doing nothing!

What is justice?

-duty to treat all patients fairly without regard to age, SES, or other variables -allocation of scarce resources

What is situational theory?

-each situation creates its own rules and principles -no prescribed rules, norms, or judgments -emphasizes the uniqueness of the situation and respect for person in that situation

Mobility: Musculoskeletal Interventions

-early ambulation -maintain proper alignment in bed -active/passive ROM -involve physical therapy -encourage patient to move in bed and turn frequently

What is secondary prevention?

-early diagnosis/treatment -EX: exams, treatments

What is primordial prevention?

-eliminate risk factors -EX: discouraging development of bad habits

Effective Traits of Therapeutic Communication

-empathy: desire to understand and be sensitive -respect: value and adjust to patient -genuineness: be truthful and real -concreteness: be stable and use simple terms -confrontation: willing to request clarification or be confronted by others

Geriatrics: Urinary Changes

-enlarged prostate gland -retention, incontinence, frequency, difficulty with initiating voiding -UTI risk (foley catheters) -benign prostatic hypertrophy (BPH) is common -prostate cancer in men -stress incontinence in women

Responding Techniques

-establish trust by introducing self -be assertive and honest -be respectful -use "I" messages -active listening -being empathetic -reflect EX: I don't know but I will find out OR I don't have time right now but I will come back later

What is common/case law?

-established by rules of custom and tradition -decisions made by judges in court cases -composed of decisions rendered in court cases by appeal courts -set precedent for next situation -results from individual cases and judicial decisions

Principle #5 of integrative nursing: integrative nursing practice is informed by ___ and uses the full range of ___ modalities to support/augment the healing process, moving from ___ to ___ intensive, depending on need and context.

-evidence -therapeutic -least -more

What is affective learning?

-expressing feelings -focuses on attitudes, opinions, and values -elements: receiving, responding, valuing, organization, internalizing values

How does anemia affect oxygenation?

-fatigue -decreased activity tolerance -increased breathlessness -increased HR -pallor

Geriatrics: Head/Neck Changes

-features more pronounced -decreased visual acuity -decreased ability to hear high pitched sounds -decreased saliva secretion -taste bud atrophy

How is the chest wall affected by trauma?

-flail chest -multiple rib fractures -chest of abdominal surgeries

Geriatrics: Cognitive Changes

-fluid intelligence decreases (reasoning/processing) -slower to learn new information -3 most common conditions: depression, delirium, dementia

Dressings: Hydrogel

-gauze or sheet dressings with water or gel -hydrates wounds and absorbs small amounts of exudate Advantages -soothing, can reduce pain -provides moist environment -debrides necrotic tissue -does not adhere to wound base -easy to remove Disadvantages -some require second dressing -monitor for periwound maceration

What is dementia?

-generalized impairment of intellectual functioning -decline in ability to perform ADL's/IADL's -gradual, progressive, irreversible

What is utilitarianism?

-greatest good for the greatest number of people -main emphasis is on the outcome/consequences -most US public health policies are based on this theory

What is anticipatory grief?

-grieving before a loss or fear of a potential loss -experienced by patients, family, and professionals -can provide time for preparation

How do you check for range of motion in the spine?

-have patient bend forward to touch toes -lateral bending of 35 degrees (side) -hyperextension of 30 degrees (bend back) -rotation of 30 degrees (twist shoulders) REVEAL GROSS RESTRICTIONS ONLY

What is primary prevention?

-health promotion -EX: education, screening, hygiene

Assessment of Mobility

-how long patient has been immobile -prior activity level -assistive devices used -review orders: physical therapy, ambulation, bed rest

Types of Urinary Incontinence: Functional

-inability or lack of motivation to reach toilet on time -causes: inaccessible toilet, mobility disorders, cognitive impairments

What are physiologic indicators of pain?

-inc. HR -change in respiratory pattern and/or rate -inc BP -dec. SpO2

Geriatrics: Gastrointestinal Changes

-increase in fatty tissue -peristalsis slows -less tolerant of certain foods -reflux -delayed gastric emptying -risk for nutritional balance

What is barrel chest?

-increased anteroposterior diameter of chest wall -lungs are over-inflated so body compensates by making room -barrel chest and accessory muscle use can cause air trapping in emphysema

Functions of Sleep

-increases mental performance -improves learning -helps storage of long-term memory -repairs body and restores energy -improves ability to cope (less irritable) -strengthens immune system (decrease inflammation hormones, increase melatonin production)

Isolation Precautions: Tier Two - Contact

-infection with multi-drug resistant organisms -major wound infection -EX: varicella zoster, herpes, C. diff Details -gown, gloves, private room or with patient with same diagnosis

What are the moral character traits?

-integrity -trustworthiness -justice -beneficence/non-maleficence -fidelity -veracity

What is cognitive learning?

-intellectual behaviors -thinking -Bloom's taxonomy -elements: remembering, understanding, applying, analyzing, evaluating, creating

What is abuse?

-intentional infliction of physical harm -injury caused by negligent acts of omission -unreasonable confinement -sexual abuse or sexual assault

Types of Urinary Incontinence: Urge

-involuntary leakage accompanied by urgency (overactive bladder) -causes: detrusor muscle over activity -risk factors: many UTIs, caffeine

Types of Urinary Incontinence: Stress

-involuntary leakage from effort exerted -cause: increase urethral mobility, poor sphincter function -risk factors: obesity, pregnancy, vaginal deliveries, surgeries

What are proper body mechanics for lifting?

-keep aligned -flex knees -wide base -use arms and legs NOT back

Prevention of workplace injuries at the nurse level

-know your capabilities -know patient's capabilities -gather enough people -know facility policies -proper body mechanics

What are some barriers to teaching?

-lack of time -lack of knowledge -patient in denial -poor nurse-patient relationship -short length of hospitalization

What is civil law?

-law relating to relationships between private parties -provides fair and equitable treatment -fines/monetary damages are usually the consequence -burden of proof is initially on plaintiff but once court acknowledges case, defendant has to prove plaintiff wrong -plaintiff wins if preponderance favors them (>50%) INCLUDES CONTRACT LAW AND TORT LAW

Complications of Wound Healing: Dehiscence

-layers of skin and tissue separate partially or fully -commonly occurs before collagen formation (3-11 days after injury) -risk factors: obesity, increased pressure

What does the corneal light reflex test assess for?

-lazy eye -visual alignment issues

Types of Urinary Incontinence: Overflow

-leakage associated with bladder distension -causes: obstruction or neurological condition, detrusor muscle weakness -symptoms: dribbling, weak stream

Documentation for educating a patient includes what?

-learning needs -SMART outcome -specific education provided -evaluation of outcomes -additional interventions used after evaluation -resources provided Documentation describes the entire teaching-learning process, promotes continuity of care, demonstrates compliance with various standards, and legally demonstrates that the nurse has met standard of care

What is psychomotor learning?

-learning new skills integrating mental and physical activity -elements: perception, set, guided response, mechanism, complex overt response, adaptation, origination

What is tort law?

-legal wrong committed by one person against the person or property of another -all torts involve a person who as been wronged and has the legal right to bring about a civil action (law suit) against the person who caused the wrong -require that plaintiff prove his/her case at a level of "clear and convincing" Intentional (both civil and criminal): invasion of privacy, defamation, assault, battery Quasi-intentional Unintentional: negligence

If a lump or mass is felt on the breast, what is important to note?

-location -size -shape -contour -consistency -mobility -pain -tenderness -discharge -number of lumps/masses

Wound Measurement

-measured in centimeters -top of wound towards head -face of clock method -measure longest part top to bottom and widest part perpendicular to length -can measure depth by using cotton swab

Treatment of depression

-meds -psychotherapy -safety assessment -ECT for resistant depression

Normal lymph nodes are:

-movable -discrete -soft -non-tender

Risk factors for HCAIs

-multiple illnesses -older age -malnourished -predisposed to infection due to disease -medical devices that bypass natural defenses

Mobility: Musculoskeletal Changes

-muscle atrophy (10% decrease each week) -osteoporosis -contractures -foot drops

Geriatrics: Musculoskeletal Changes

-muscle fibers become smaller -decrease in bone density and bone mass -osteoporosis (1 in 2 women and 1 in 4 men will break a bone because of this)

What are the 3 different types of ethics?

-normative ethics -metaethics -descriptive ethics

What are rights of the nurse in regard to court cases?

-notice of time and place of hearing -attorney -clear statement of charges -confront and produce witnesses -record of proceedings -fair determination of presiding body -appeal for judicial review

Sleep Promotion Methods

-offer foods that help promote sleep (high carbs, decaf teas, warm milk) -maintain safety of patient -educate about sleep hygiene -educate about sleep-inducing medications -avoid strenuous activity 2 hours before bed -schedule care that avoids disrupting sleep -create comfortable environment -promote relaxation -support bedtime routines

Dressings: Gauze Sponge

-oldest and most common -very absorbent -can be saturated with solutions and used to clean and pack Purpose: to provide moisture to wound and allow drainage to be wicked into dry cover gauze

What is the Confrontation Test?

-one eye is covered -gross measure of peripheral vision -tests for visual acuity and field of vision -tests for PERRLA -compares person's peripheral vision with yours Impaired in individuals with stroke or glaucoma

Dressings: Foam and Calcium Alginate

-other forms of dressings -used for wounds with large amounts of exudate and those that need packing -highly absorbent -does not cause trauma on removal -cannot be used for dry wounds -needs second dressing

What is teleological theory?

-outcome focused -ends justify means -goal is to decrease suffering -morality is established by majority rule -human reason is the basis for authority in all situations In this theory, euthanasia is the right thing to do

What are some of the most common causes of workplace injuries?

-overexertion -improper lifting and bending -transferring patients -inadequate assistance -inadequate use of lift and transfer devices -pushing beds

Sexuality: What are the 5 P's?

-partners -practices -prevention of pregnancy -protection from STDs -past history of STDs

What are the four primary sources of hospital revenue?

-patient care services (inpatient and outpatient) -non-patient care services (cafeterias, parking garages, gift shop) -investment income -grants and donations

What is autonomy?

-patient's right to self-determination without outside control -assumes rational thinking on the part of the individual -challenged when rights of others infringed upon by individual -freedom to make choices and decisions oneself

What are the 3 values of Banner Medical Center?

-people above all (by treating those we serve with compassion, dignity, and respect) -excellence (by acting with integrity and striving for the highest quality of care and serve) -results (by exceeding the expectations of those we serve and those we set for ourselves)

What are the different forms of depression?

-persistent depressive disorder: symptoms last at least 2 years -postpartum depression: symptoms after childbirth -psychotic depression: depression + psychoses -seasonal affective disorder: onset during winter months

Isolation Precautions: Tier Two - Specialized Environments

-positive airflow room -increased air circulation -no fresh flowers, fruits, or veggies -HEPA filter -limited visitors (no children, no sick) -must wear gloves, mask, gown if there are visitors

How is the chest wall affected with obesity?

-presence of sleep apnea -increased work of breathing -decreased lung volumes

Mobility: Integumentary Interventions

-prevention of skin breakdown -frequent position changes (every 2 hours) -meticulous skin care -thorough skin assessment (Braden scale)

What are gowns used for and why are they needed?

-prevents soiling clothes -prevents coming in contact with infectious material or bodily fluids/blood

What are the attributes of economics?

-price and cost -supply and demand -cost effectiveness -efficiency -value

What are the roles of a nurse generalist?

-provider of direct and indirect care for individuals, families, groups, etc. -designer/manager/coordinator of care -member of a profession

What is the purpose of a functional health pattern?

-provides framework for assessment -helps address common nursing problems -directs nurse on what info to obtain -the order to collect info -amount of detail needed for assessment -structure for managing data

Pressure Ulcer: Suspected Deep Tissue Injury

-purple or maroon non-blanching area of intact skin or blood-filled blister -can rapidly turn into ulcers involving all tissue layers -can begin as a thin blister over dark wound bed

How do you evaluate teaching/education?

-questioning -returning demonstration -patient verbalizing understanding

What are the tests used to test coordination and skilled movements?

-rapid alternating movements (RAM) -touching thumb to each finger -finger-to-finger test -finger-to-nose test -heel-to-shin test

Nursing Diagnosis: Knowing when to communicate

-readiness for enhanced communication -impaired verbal communication -knowledge deficit

What is descriptive ethics?

-referred to as scientific rather than philosophical -describes what people think about morality or when they want to describe how people actually behave (their morals)

What are feminist ethics?

-requires context of the situation -takes into account variances in culture/societal norms -what is right for one group may not be right for another

What is tertiary prevention?

-restoration and rehab -EX: post-op care, hospital recuperation

Symptoms of neurogenic bladder

-retention with or without incontinence -feeling of bladder distension

What is a deontological theory?

-right or wrong based on duty/obligation -does not look at consequences of action -individual has clear direction in how to act in all situations -uses words like "never" and "always"

What teaching methods are used for afferent learning?

-role play -discussion

What teaching methods are used for cognitive learning?

-role playing -discussion -lecture -Q & A

What is statutory law?

-rules passed by state or congress (federal) -can be broken down to civil or criminal EXAMPLES: -Nurse Practice Act: state -Good Samaritan Laws: state -Americans with Disabilities Act: federal -HIPAA: federal

Nursing Care for Individuals with Dementia

-safety, physical, and psychosocial needs of patient and family -needs change as dementia progresses -maintain routine when possible -watch for nonverbal signs of anxiety, panic, or stress -allow adequate response time from patient (takes them longer to process) -give directions in simple steps (guide, cue, prompt)

What are "standards of practice"?

-same as standard level of care -level of competence

What are the different forms of healthcare funding?

-self pay -private -federal and state funding (Medicare/Medicaid)

What are the 3 values of Carondelet?

-service of the poor -integrity -reverence

Mobility: Cardiovascular Interventions

-sitting up in bed -isometric exercises (contractions of particular muscle or muscle group) -avoiding valsava maneuver (forceful exhalation against closed airway).....can cause arrhythmia, decrease in heart rate, and fainting Preventing DVTs -Thrombo embolic deterrent (TED) hose -Sequential compression devices (SCDs) -Anticoags -Early ambulation

Mobility: Integumentary Changes

-skin irritation and fragility due to reduced circulation, moisture, pressure, and friction -risk for pressure ulcers and skin tears

Pressure ulcer dressings depend on...

-stage of pressure ulcer -type of tissue in wound -function of dressing

What are some of the benefits of using SBAR?

-standardized communication format -provides structure -incorporates only necessary info -systematically organized -helps keep conversation focused, objective, and unbiased

Mobility: Urinary Changes

-stasis of urine leads to urinary calculi -risk for dehydration and decreased urine output -UTIs due to foley catheter

Wound classifications

-status of skin integrity -cause of wound -severity of tissue injury -cleanliness of wound -descriptive qualities (color)

What is surgical asepsis?

-sterile technique -chemical, steam, gas -sterilization: complete removal of all microorganisms

Isolation Precautions: Tier Two - Airborne

-susceptible host must breath in pathogen (direct) -EX: varicella zoster, measles, tuberculosis Details -private room, negative pressure air flow, increased air exchanges, HEPA filter, N95 respirator, patient must wear mask outside of room

What is depression?

-symptoms must be present for at least 2 weeks to be diagnosed -symptoms may present as somatic (headache, back problems, chronic pain) -general symptoms: lack of motivation, lack of pleasure, sadness, etc. -some individuals may be too embarrassed to seek care or there is a stigma in the community UNIVERSAL SCREENING IS STANDARD OF CARE REGARDLESS OF S/S

Complications of Wound Healing: Evisceration

-total separation of skin/tissue layers -visceral organs come through wound opening -surgical emergency

Dressings: Self-Adhesive

-transparent film that traps moisture over a wound -ideal for small superficial wounds (EX: stage 1 pressure ulcer) Advantages -adheres to undamaged skin -serves as a barrier to external fluids -allows wound surface to breathe through dressing -permits viewing -does not require secondary dressing

Wound Assessment

-type of dressing currently in place -amount of drainage on dressing -appearance of periwound skin -appearance of wound bed -type and amount of drainage overall -odor -tunneling or undermining -pain -is it approximated (closed/open)

Classic symptoms of UTIs

-urgency/frequency -dysuria/burning -bladder cramps/spasms -itching -noturia -fever -hematuria

What are masks/respirators used for and why are they needed?

-used for airborne or droplet diseases -patient wears mask outside of room -small droplets: use respirator -large droplets: use mask

What are gloves used for and why are they needed?

-used when coming in contact with blood, bodily fluids, secretions/excretions (not sweat), mucuous membranes, non-intact skin, contaminated surfaces/equipment -hand hygiene before and after gloving -change when heavily contaminated

What is the Rinne test used for?

-uses a tuning fork to have patient determine when they hear the ringing/vibration start and stop -assess hearing loss

What are the types of normative ethics and morals?

-virtue: focus on moral character of agent -deontology: focus on the act being performed as good/bad irrespective of consequence -consequentialism: doing whatever brings the best consequence/outcome no matter the act

What are the different learning styles?

-visual -auditory -tactile/psychomotor -reading/writing

Tips for clean intermittent self catheterization

-wash hands -timing: every 3-4 hours (start with 2-3 hours) -amount of urine removed: 350-400 mL -fluid intake: 250 mL/2 hr interval (up to 2L/day at regular intervals)

Who is at highest risk for UTIs?

-women with short urinary tract -men >50YO (enlarged prostate) -those with indwelling catheter

Dressings: Hydrocolloid

-wound contact layer forms a gel as exudate is absorbed -support healing in clean granulating wounds -useful on shallow-to-moderately deep ulcers -cannot absorb drainage from heavily draining wounds -most leave residue in wound bed Advantages -maintains wound moisture -slowly liquefies necrotic debris -self-adhesive and molds well -can be left in place for 3-5 days

Each day, ___ in ___ hospitalized patients has at least one HCAI

1 in 25

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1, 3, 5, 4, 2 1. Remove gloves. 3. Remove eyewear or goggles 5. Untie waist and neck strings of gown. Remove gown, rolling it 4. Untie top and then bottom mask strings and remove from face. 2. Perform hand hygiene.

Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.

1, 5, 7, 4, 6, 3, 2 1. Identify patient using two identifiers. 5. Assess the condition of the patient's skin and circulation of the legs. 7. Use tape measure to measure patient's legs to determine proper stocking size. 4. Turn the stocking inside out until heel is reached. 6. Place toes into foot of the stocking. 3. Slide the remainder of the stocking over the patient's heel and up the leg 2. Smooth any creases or wrinkles.

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? 1. "CPOE reduces transcription errors." 2. "CPOE reduces the time needed for health care providers to write orders." 3. "CPOE eliminates verbal and telephone orders from health care providers." 4. "CPOE reduces the time nurses use to communicate with health care providers."

1. "CPOE reduces transcription errors."

The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."

1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire."

The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

1. "I don't need to use condoms since there is no risk for pregnancy." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

Which statement made by the parent of a school-age child requires follow-up by the nurse? 1. "I encourage evening exercise about an hour before bedtime." 2. "I offer my daughter a glass warm milk before bedtime." 3. "I make sure that the room is dark and quiet at bedtime." 4. "We use quiet activities such as reading a book before bedtime."

1. "I encourage evening exercise about an hour before bedtime."

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."

1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet."

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."

1. "I'll recognize abnormal lumps because they are very painful."

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (NP) informs her that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." How should the NP respond? (Select all that apply.) 1. "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, but you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

1. "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 have the highest incidence of STIs."

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 ​PM​, changed the dressing over the patient's abdominal incision at 5:34 ​PM​, and administered Ancef 1 g IV at 8:00 ​PM​. Using correct military time, label the documentation for each task with the time that it was completed. 1.____Morphine 2 mg IV given for pain rating of 8/10 2.____Dressing changed over midline abdominal incision using aseptic technique 3.____Ancef 1 g given IVPB over 30 minutes.

1. 1545 2. 1734 3. 2000

Match the vision with its value: 1. Normal vision 2. Visually impaired 3. Legally blind 4. Totally blind A. 20/20 or better B. 20/50 or worse C. No light perception D. 20/200 or worse

1. A 2. B 3. D 4. C

Match the barrier to pain assessment to its developmental age: 1. Infant/toddler 2. Preschooler 3. School-aged 4. Adolescent 5. Adult 6. Older adult A. Nonverbal, always crying so do not know why they are in pain B. worried, lack of health insurance (financial barriers), time (work, school), will not think they do not have pain C. embarrassment, can be seeking attention, D. do not understand pain, do not have experience with pain so little pain may be the worst pain they experience, distractibility E. how peers view them will view them, torsion (testicles will spontaneously twist and lose blood circulation), embarrassment, sign of weakness F. denial, hard time with aging, scared to be put in a home, fear of losing independence, forget they are in pain

1. A 2. D 3. C 4. E 5. B 6. F

Which patient is most likely to experience sensory overload? 1. A patient in the intensive care unit whose pain is not well controlled 2. A patient with a protective patch on her right eye following cataract surgery 3. A woman whose hearing aids were lost when she transferred to a long-term care facility 4. A visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities

1. A patient in the intensive care unit whose pain is not well controlled

The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this age-group. 3. Lesbian, gay, bisexual, and transgender (LGBT) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance.

1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 3. Lesbian, gay, bisexual, and transgender (LGBT) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety.

The body alignment of the patient in the tripod position includes the following: (Select all that apply.) 1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees 4. Axillae resting on the crutch pads 5. Bent knees and hips

1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction

1. An intestinal obstruction

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) 1. An observation of how a patient turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other patients with similar problems

1. An observation of how a patient turns and moves in bed 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film

Components of a General Survey

1. Apparent state of health (age, nutritional status) 2. Body structure 3. Alert and oriented x4 (person, place, time, situation) 4. Skin color 5. Personal hygiene 6. Posture/position 7. Obvious physical deformities 8. Mood/Affect 9. Speech 10. Mobility

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

1. Appearance and behavior

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over skin 2. Apply ice for 5 minutes or until numbness occurs 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1. Apply ice using firm pressure over skin 2. Apply ice for 5 minutes or until numbness occurs 5. Use a slow, circular steady massage.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1. Ask the patient about any allergies and reactions.

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) 1. Avoid grapefruit and grapefruit juice, which impair drug absorption. 2. Increase the amount of carbohydrates for energy. 3. Take a multivitamin that includes vitamin D for bone health. 4. Cheese and eggs are good sources of protein. 5. Limit fluids to decrease the risk of edema.

1. Avoid grapefruit and grapefruit juice, which impair drug absorption. 3. Take a multivitamin that includes vitamin D for bone health. 4. Cheese and eggs are good sources of protein.

Match the advanced practice nurse specialty with the statement about the role. 1. Clinical nurse specialist ​ 2. Nurse anesthetist ​ 3. Nurse practitioner 4. Nurse-midwife ​ A. Provides independent care, including pregnancy and gynecological services B. Expert clinician in a specialized area of practice such as adult diabetes care C. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions D. Provides care and services under the supervision of an anesthesiologist

1. B 2. D 3. C 4. A

Components of a Health History

1. Biographical data 2. Reason for care 3. Patient expectations 4. Current health status (PQRSTU) 5. Past history 6. Family history 7. Psychosocial history 8. Spiritual and cultural history 9. Review of body systems

What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

1. Bladder scan the patient immediately after voiding.

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? (Select all that apply.) 1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors 5. Increased computer use

1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool

1. Bruising 3. Bleeding gums 4. Coffee ground-like vomitus

Match the classification of integrative therapy to its description: 1. Mind-body interventions 2. Natural products/biologically-based therapies 3. Manipulative and body-based methods 4. Energy therapies 5. Movement therapies 6. Whole medical systems A. acupressure, massage, chiropractic care B. dance, pilates C. meditation, breath work, yoga D. healing touch, reiki, biofield therapies, bioelectromagnetic-based therapies E. traditional Chinese medicine, naturopathic medicine, indigenous healing systems F. herbals, supplements, probiotics

1. C 2. F 3. A 4. D 5. B 6. E

The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question asked by the nurse demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?

1. Can you tell me your sexual orientation?

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.) 1. Caregiver 2. Autonomy and accountability 3. Patient advocate 4. Health promotion 5. Lobbyist

1. Caregiver 2. Autonomy and accountability 3. Patient advocate 4. Health promotion

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I A 2. Category/stage II D 3. Category/stage III B 4. Category/stage IV C a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1. Category/stage I a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. 2. Category/stage II d. Partial-thickness skin loss or intact blister with serosanguinous fluid. 3. Category/stage III b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. 4. Category/stage IV c. Full thickness tissue loss; muscle and bone visible. May include undermining.

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1. Check for needed adaptive equipment. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point.

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) 1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 4. Release both limbs at the same time to perform range of motion (ROM) 5. Inspect the skin under each restraint

1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 5. Inspect the skin under each restraint

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1. Collaboration between staff members from sending and receiving departments 3. Using a standardized transfer policy and transfer tool

Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a patient's assessment data

1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert

Which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Age 3. Spirituality 4. Personal beliefs 5. Previous experiences with death 6. Gender 7. Level of education 8. Degree of social support

1. Culture 3. Spirituality 4. Personal beliefs 5. Previous experiences with death 8. Degree of social support

Match the hearing diseases/disorders to its description: 1. Conductive hearing loss 2. Sensorineural hearing loss 3. Presbycusis 4. Central auditory processing disorder 5. Tinnitis 6. Meniere's disease A. brain is not processing sound wave properly B. natural aging of hearing C. inner ear fluid imbalance; room is spizzing, dizziness D. due to blockage (i.e., buildup of wax) E. ringing in the ear F. nerve damage or damage to nerve fibers

1. D 2. F 3. B 4. A 5. E 6. C

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1. Debridement

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

1. Decreased peristalsis

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Delirium. 2. Depression. 3. New-onset dementia. 4. Worsening dementia.

1. Delirium.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the ear mold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.

1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 4. Discuss the importance of having wax buildup in the ear canal removed.

Primary goals of nursing

1. Determine a person's or system's response to human problems 2. Provide holistic care 3. Implement interventions aimed at wellness promotion and disease prevention 4. Focus on helping the person obtain and maintain their highest level of wellness, functioning, and self-care

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) 1. Difficulty paying his bills 2. Seeing his pastor as a means of support 3. Age of patient (46 years) 4. Stress from the divorce and the loss of a job 5. Family practice of not routinely seeing a health care provider

1. Difficulty paying his bills 5. Family practice of not routinely seeing a health care provider

Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves

1. Disposable gown 2. N 95 respirator mask 5. Gloves

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) 1. Documents a medication given by another nursing student. 2. Includes the date and time of the entry into the medical record. 3. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. 4. Leaves a slip of paper with her username and password in the patient's room. 5. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

1. Documents a medication given by another nursing student. 4. Leaves a slip of paper with her username and password in the patient's room.

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.) 1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if they have trouble hearing 5. Look behind toward the blind spot 6. Stop driving at age 75

1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot

What are the 4 elements of liability?

1. Duty: duty to care for patient 2. Breach of duty: need to meet specific standard of care 3. Causation: failed to meet standard of care 4. Damages: damages or injuries resulted for which compensation is sought

The nurse spends time with the patient and family reviewing the dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? 1. Educator 2. Advocate 3. Caregiver 4. Case manager

1. Educator

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy

1. Encouraging use of an overhead trapeze for positioning and transfer

A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? 1. Four-point 2. Three-point 3. Two-point 4. Swing-through

1. Four-point

As age increases, sleep is more (1)_____________ and more time is spent in (2)___________ stages of sleep.

1. Fragmented 2. Lighter

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 6. Applying a moisture barrier ointment

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

1. Gaining an understanding of patient's motivations 3. Recognizing patient's strengths and supporting their efforts 5. Identifying differences in patient's health goals and current behaviors

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high-school students. Which points should be included in the education? (Select all that apply.) 1. Go to bed at the same time each night. 2. Study in your bedroom to have a quiet place. 3. Turn on the television to help you fall asleep. 4. Avoid drinking coffee or soda before bedtime. 5. Turn off your cell phone at bedtime.

1. Go to bed at the same time each night. 4. Avoid drinking coffee or soda before bedtime. 5. Turn off your cell phone at bedtime.

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? 1. Have the patient perform a Valsalva maneuver 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line 3. Have the patient take a deep breath and hold it 4. Notify the health care provider immediately

1. Have the patient perform a Valsalva maneuver

What is your role as a nurse during a fire? (Select all that apply.) 1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 4. Single carry patients out 5. Direct ambulatory patients

1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 5. Direct ambulatory patients

Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine if the ostomy is healing appropriately

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine if the ostomy is healing appropriately

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1. Impaired vision 4. Leg weakness 5. Exercise history

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) 1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets 6. Staircases with handrails

1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

1. Include communication while performing tasks such as changing dressings and checking vital signs.

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet 2. Use a low-volume enema daily 3. Avoid gluten in the diet 4. Take laxatives twice a day 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day 7. Take probiotics 5 times a week

1. Increase fiber and fluids in the diet 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day

The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely: 1. Increase the patient's risk for falls and injuries. 2. Result in less stress on the patient's joints. 3. Decrease the amount of work required for patient movement. 4. Allow for mobility in spite of the aging effects on the patient's joints.

1. Increase the patient's risk for falls and injuries.

What is the chain of infection?

1. Infectious agent 2. Reservoir 2. Portal of exit 3. Mode of transmission 4. Portal of entry 5. Susceptible host

General order of Physical Assessment Technique

1. Inspect 2. Palpate 3. Auscultate 1, 3, 2 FOR ABDOMEN!

Which of the following statements best explains the actions of therapeutic touch (TT)? 1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield 2. Intentionally heals specific diseases or corrects certain symptoms 3. Is overwhelmingly effective in many conditions 4. Is completely safe and does not warrant any special precautions

1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile.

1. It allows migration of organisms into the bladder. 3. It obstructs the normal flushing action of urine flow.

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1. Keep the bowels regular. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back.

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) 1. Listen attentively to the patient's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the patient's fatigue.

1. Listen attentively to the patient's story. 2. Use gestures that reinforce your questions or comments. 4. Maintain direct eye contact.

Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform? 1. Moving from an acute illness to a health promotion, illness prevention model 2. Moving from an illness prevention to a health promotion model 3. Moving from an acute illness to a disease management model 4. Moving from a chronic care to an illness prevention model

1. Moving from an acute illness to a health promotion, illness prevention model

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? 1. Normal 2. Complicated 3. Chronic 4. Disenfranchised

1. Normal

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the surgeon. 4. Cover the area with sterile, saline-soaked towels immediately.

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) 1. Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. 2. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 4. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. 5. Nurses play an essential role in the safe use of complementary therapies. 6. Nurses learn how to provide all of the complementary modalities during their basic education.

1. Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. 2. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 4. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. 5. Nurses play an essential role in the safe use of complementary therapies.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.

1. Only the patient should push the button. 3. The PCA system can set limits to prevent overdoses from occurring. 5. Do not push the button to go to sleep.

Label each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]). 1.____Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2.____"The pain increases every time I try to turn on my left side." ​3.____Acute pain related to tissue injury from surgical incision​. 4.____Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

1. P 2. S 3. A 4. O

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient's health management values.

1. Patient's level of function.

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1. Patient's self-report 2. Behaviors 3. Surrogate (wife) report 4. Vital sign changes

1. Patient's self-report

Before transferring a patient from the bed to a stretcher, which assessment data do the nurse need to gather? (Select all that apply.) 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. Nutritional intake

1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment

A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply.) 1. People who are homeless. 2. People with respiratory conditions. 3. People with cardiovascular conditions. 4. The very old. 5. People with kidney disorders.

1. People who are homeless. 3. People with cardiovascular conditions. 4. The very old.

A nurse is conducting a home visit with an older-adult couple. While in the home the nurse weighs each individual and reviews the 3-day food diary with them. She also checks their blood pressure and encourages them to increase their fluids and activity levels to help with their voiced concern about constipation. The nurse is addressing which level of need according to Maslow? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-actualization

1. Physiological

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed. 2. Place the patient in a belt restraint. 3. Provide one-on-one observation of the patient. 4. Apply wrist restraints.

1. Place a bed alarm device on the bed.

A 42-year-old sexually active female is being assessed by a nurse during her annual physical. The woman states that she has not had a period for the last 2 months. The nurse knows that the most likely cause of this occurrence is: 1. Pregnancy. 2. Illicit drug use. 3. Chlamydia infection. 4. Early-onset menopause.

1. Pregnancy.

At 1oon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to resume normal operations 4. Evacuate patients per the disaster plan

1. Prepare for an influx of patients

To best assist a patient in the grieving process, which of the following is most helpful to determine? 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status.

1. Previous experiences with grief and loss

A nurse is presenting a program to workers in a factory covering safety topics, including the wearing of hearing protectors when workers are in the factory. Which level of prevention is the nurse practicing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Quaternary prevention

1. Primary prevention

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

When planning care for the dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing patients as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Using a preferred name

1. Providing respect 2. Viewing patients as a whole 4. Showing interest 5. Being present 6. Using a preferred name

75% of CO2 transport is transported in the (1)______________ and 25% is transported in the (2)___________.

1. Red blood cells 2. Plasma

A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

1. Sharing information about senior transportation services 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What is your priority nursing intervention? 1. Stop the instillation 2. Ask the patient to take deep breaths to decrease the pain 3. Add soapsuds to the enema 4. Tell the patient to bear down as he would when having a bowel movement

1. Stop the instillation

The nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat the large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil (Provigil).

1. Take brief, 20-minute naps no more than twice a day. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil (Provigil).

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea

1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Teaching how activities such as reading and using crossword puzzles provide stimulation 2. Moving him to a room away from the nurse's station 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions 5. Providing auditory stimulation for the patient by keeping the television on continuously

1. Teaching how activities such as reading and using crossword puzzles provide stimulation 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination if the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1. The loss of his work role 4. How the wife expects household tasks to be divided in the home in retirement

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 2. The nurse asks the patient what caused his fall. 3. The nurse asks the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower-limb strength. 5. The nurse asks the patient what pain medication is most effective in managing his pain.

1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 4. The nurse assesses the patient's lower-limb strength.

A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body.

1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves.

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) 1. The patient's name, age, and admitting diagnoses 2. The discussion of any allergies to food and medications that the patient has 3. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" 4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol 5. Description of any unresolved problems and current interventions in place

1. The patient's name, age, and admitting diagnoses 2. The discussion of any allergies to food and medications that the patient has 4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol 5. Description of any unresolved problems and current interventions in place

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) 1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 2. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. 3. The fat emulsion will help control hyperglycemia during periods of stress. 4. The parenteral nutrition will help your wounds heal. 5. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 3. The fat emulsion will help control hyperglycemia during periods of stress. 4. The parenteral nutrition will help your wounds heal.

A postoperative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral routes

1. The sedative administered may have helped him sleep, but it is still necessary to assess pain.

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F).

1. The skin around the wound is tender to touch. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F).

A grieving patient complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? 1. These are normal symptoms of grief. 2. There is a need for pharmacological support for insomnia. 3. The patient is experiencing complicated grief. 4. These are common complaints of the admitted patient.

1. These are normal symptoms of grief.

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

1. Thrombus formation 2. Increased cardiac workload 5. Orthostatic hypotension

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction

1. Transcutaneous electrical nerve stimulation (TENS) 3. Provide back massage 4. Reposition the patient

What is the physiologic mechanism of noxious pain?

1. Transduction -Injured tissue releases chemicals that propagate pain message -Action potential moves along an afferent fiber to the spinal cord 2. Transmission -The pain impulse moves from the spinal cord to the brain 3. Perception of pain 4. Modulation -Neurons from brainstem release neurotransmitters that block the pain impulse

What are the physical changes that occur as death approaches? (Select all that apply.) 1. Unresponsiveness 2. Erythema 3. Mottling 4. Restlessness 5. Increased urine output 6. Weakness 7. Incontinence

1. Unresponsiveness 3. Mottling 4. Restlessness 6. Weakness 7. Incontinence

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g., transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.) 1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

What is Virchow's triad?

1. Venous stasis 2. Hypercoagulability (increased clotting) 3. Trauma to a vessel

A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase

1. Working phase

First Aid for Wounds

1. control/stop bleeding (pressure) 2. clean wound (normal saline preferred) 3. protect wound with bandage

Match the type of pain to its definition: 1. Acute pain 2. Chronic pain 3. Chronic episodic 4. Somatic 5. Visceral 6. Referred 7. Idiopathic a) Pain that comes and goes, but is long term b) Pain of the body's internal organs, a subtype of nociceptive pain c) Pain that has no explanation d) Pain that is felt in the a different area; associated with visceral pain e) Pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection f) Pain of the muscles, joints, connective tissues and bones g) A painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process

1. e 2. g 3. a 4. f 5. b 6. d 7. c

How often should an incentive spirometer be used?

10 times per hour

How much of communication is verbal?

10-20%

Vitals: Respirations

12 - 20 rpm

What is prehypertension?

120-139/80-89

Braden Scale: what score indicates onset of risk in intensive care?

13

Braden Scale: what score indicates onset of ulcer risk?

18

Place the following in order of sequence for condom application and usage. 1. Gently squeeze air out from the tip of the condom; leave space at the tip. 2. Check the condom package for damage, expiration date, and protection from STIs. 3. After ejaculating, hold onto condom while pulling out. 4. Place on erect penis and unroll to the base of the penis.

2, 1, 4, 3 2. Check the condom package for damage, expiration date, and protection from STIs. 1. Gently squeeze air out from the tip of the condom; leave space at the tip. 4. Place on erect penis and unroll to the base of the penis. 3. After ejaculating, hold onto condom while pulling out.

The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation

2, 3, 4, 1

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"

2, 4, 1, 5, 3 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 4. "Tell me what brought you to the hospital." 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" 3. "I have no further questions. Thank you for your patience."

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because these can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls."

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F).

2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F). 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis."

Which statement made by a nurse shows that the nurse is engaging in an activity to help cope with secondary traumatic stress and burnout? 1. "I don't need time for lunch since I am not very hungry." 2. "I am enjoying my quilting group that meets each week at my church." 3. "I am going to drop my gym membership because I don't have time to go." 4. "I don't know any of the other nurses who met today to discuss hospital-wide problems with nurse satisfaction."

2. "I am enjoying my quilting group that meets each week at my church."

Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? 1. "You are never too old to begin an exercise program." 2. "My granddaughter and I walk together around the high school track 3 times a week." 3. "I purchased a subscription to a runner's magazine for my grandson for Christmas." 4. "When I was a child, I exercised more than I see kids doing today."

2. "My granddaughter and I walk together around the high school track 3 times a week."

After a class on Pender's health promotion model, students make the following statements. Which statement does the faculty member need to clarify? 1. "The desired outcome of the model is health-promoting behavior." 2. "Perceived self-efficacy is not related to the model." 3. "The individual has unique characteristics and experiences that affect his or her actions." 4. "Patients need to commit to a plan of action before they adopt a health-promoting behavior."

2. "Perceived self-efficacy is not related to the model."

As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast self-examination for the women's group. Which statement made by one of the participants is related to the individual's perception of susceptibility to an illness? 1. "I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly." 2. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer." 3. "Since I am only 25 years of age, the risk of breast cancer for me is very low." 4. "I participate every year in our local walk/run to raise money for breast cancer research."

2. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer."

A patient comes to the local health clinic and states: "I've noticed many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? 1. "Walking is OK. I really think running is better." 2. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" 3. "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." 4. "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

2. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?"

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? 1. "Only your family can read your medical record." 2. "You have the right to read your record." 3. "Patients are not allowed to read their records." 4. "Only health care workers have access to patient records."

2. "You have the right to read your record."

Which is the correct gait when a patient is ascending stairs on crutches? 1. A modified two-point gait. (The affected leg is advanced between the crutches to the stairs.) 2. A modified three-point gait. (The unaffected leg is advanced between the crutches to the stairs.) 3. A swing-through gait 4. A modified four-point gait. (Both legs advance between the crutches to the stairs.)

2. A modified three-point gait. (The unaffected leg is advanced between the crutches to the stairs.)

What role do patients have in complementary and alternative therapies? 1. Submissive to the practitioner 2. Actively involved in the treatment 3. Allow practitioner to experiment 4. Total believer in what is being taught

2. Actively involved in the treatment

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 5. Staff encourage family involvement in care planning and assisting with physical care.

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: 1. Educator 2. Advocate 3. Caregive 4. Case manager

2. Advocate

Which of the following nursing actions do you take after placing a bedpan under an immobilized patient? 1. Lift the patient's hips off the bed and slide the bedpan under the patient 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Encourage family to only visit for short periods of time. 4. Provide the patient with a private room close to the nurse's station.

2. Allow the patient to determine timing and scheduling of interventions.

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day

2. Ambulate patient to chair in the hall

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? 1. Denial 2. Anticipatory grief 3. Yearning and searching 4. Dysfunctional grief

2. Anticipatory grief

The nurse is completing an admission history on a patient and says, "As a routine part of your medical history, it's important to include the sexual aspects of your life. Would it be alright if we discussed this?" This is an example of the nurse using the PLISSIT model to: 1. Place the patient in control of the situation. 2. Ask permission to discuss sexuality issues. 3. Provide the patent with limited information about sexual issues. 4. Ask the patient to provide sensitive information.

2. Ask permission to discuss sexuality issues.

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record

2. Assess the catheter and drainage tubing for obvious occlusion

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs

2. Assess the intake and output from system

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? 1. Have patient follow hospital routines. 2. Avoid waking patient for nonessential tasks. 3. Give prescribed sleeping medications at dinner. 4. Turn television on low to late-night programming.

2. Avoid waking patient for nonessential tasks.

A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (Select all that apply.) 1. Always fail and cause illness and disease 2. Cause negative responses over time 3. React the same way for all individuals 4. Protect an individual from harm in the short term

2. Cause negative responses over time 4. Protect an individual from harm in the short term

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? 1. Institute isolation precautions 2. Clean the central line port through which the TPN is infusing with antiseptic 3. Change the TPN tubing every 24 hours 4. Monitor glucose levels to watch and assess for glucose intolerance

2. Clean the central line port through which the TPN is infusing with antiseptic

While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the patient coughed. Which finding should the nurse document from the lung assessment? 1. Rhonchi 2. Coarse crackles 3. Sibilant wheeze 4. Pleural friction rub

2. Coarse crackles

Which of the following cause Clostridium difficile infection? (Select all that apply.) 1. Chronic laxative use 2. Contact with C. difficile bacteria 3. Overuse of antibiotics 4. Frequent episodes of diarrhea caused by food intolerance 5. Inflammation of the bowel

2. Contact with C. difficile bacteria 3. Overuse of antibiotics

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

2. Dehydration

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Hypoglycemic reaction.

2. Depression.

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

2. Difficulty arousing the patient

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions

2. Droplet precautions

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2. Hanging the urinary drainage bag below the level of the bladder

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs. 4. Stand one step ahead of mom at the top of the stairs. 5. Place yourself alongside your mom and hold onto her waist

2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs.

Which of the following Internet resources can help consumers compare quality care measures? (Select all that apply.) 1. WebMD 2. Hospital Compare 3. Magnet Recognition Program 4. Hospital Consumer Assessment of Healthcare 5. The American Hospital Association's webpage.

2. Hospital Compare 4. Hospital Consumer Assessment of Healthcare

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2. Ice bag

An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the bod

2. Inattention and neglect, especially to the left side 4. Visual spatial alterations such as loss of half of a visual field

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning.

2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.

Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed.

2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.) 1. Regular participation in a book club 2. Lack of interest in exercise 3. Difficulty falling asleep 4. Lack of desire to go to work 5. Anxiety while working

2. Lack of interest in exercise 3. Difficulty falling asleep 4. Lack of desire to go to work 5. Anxiety while working

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further

2. Leave the catheter there and start over with a new catheter

The nurse assesses the following risk factors for coronary artery disease (CAD) in a female patient. Which factors are classified as genetic and physiological? (Select all that apply.) 1. Sedentary lifestyle 2. Mother died from CAD at age 48 3. History of hypertension 4. Eats diet high in sodium 5. Elevated cholesterol level

2. Mother died from CAD at age 48 3. History of hypertension 5. Elevated cholesterol level

A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange is an example of which element of the transactional communication process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent

2. Obtaining feedback

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4. Confirmation

2. Open-ended

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2. Palliative care is for any patient, any time, any disease, in any setting. 4. Palliative care relieves the symptoms of illness and treatment.

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? 1. Fastening tube to the gown with new tape 2. Placing patient supine while giving a bath 3. Hanging a new container of enteral feeding 4. Ambulating patient with enteral feedings still infusing

2. Placing patient supine while giving a bath

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member

2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight

When providing postmortem care, which action is a priority for the nurse? 1. Locating the patient's clothing 2. Providing culturally and religiously sensitive care in body preparation 3. Transporting the body to the morgue as soon as possible 4. Providing postmortem care to protect the family of the deceased from having to view the body

2. Providing culturally and religiously sensitive care in body preparation

Which of the following most motivates a patient to participate in an exercise program? 1. Providing a patient with a pamphlet on exercise 2. Providing information to the patient when he or she is ready to change behavior 3. Explaining the importance of exercise at the time of diagnosis of a chronic disease 4. Providing the patient with a booklet with examples of exercises 5. Providing the patient with a prescribed exercise program

2. Providing information to the patient when he or she is ready to change behavior

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication

2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation

What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

2. Risk factors that place the patient at risk for skin breakdown

The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected negatively by some medications. 3. Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. 4. It is not unusual for men with health issues to experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

2. Sexual function can be affected negatively by some medications. 4. It is not unusual for men with health issues to experience erectile dysfunction.

The nurse is providing health teaching for a patient using herbal compounds such as kava for sleep. Which points need to be included? (Select all that apply.) 1. Can cause urinary retention 2. Should not be used indefinitely 3. May have toxic effects on the liver 4. May cause diarrhea and anxiety 5. Are not regulated by the U.S. Food and Drug Administration (FDA)

2. Should not be used indefinitely 3. May have toxic effects on the liver 5. Are not regulated by the U.S. Food and Drug Administration (FDA)

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.) 1. Yell so the patient can hear you. 2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 4. Send a written copy of the instructions home with him and tell him to have the family review them. 5. Include the family caregiver in the teaching session.

2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 5. Include the family caregiver in the teaching session.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the bestnursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program

2. Start a scheduled toileting program

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2. Taking a total of eight different medications during the day 4. Patient's health history of renal disease

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Limit intake of cholesterol to less than 400 mg/day. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? 1. The nurse caring for the patient forgot to document on the pulmonary system. 2. The EMR uses a charting-by-exception format. 3. The computer shut down unexpectedly when the nurse was documenting the assessment. 4. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

2. The EMR uses a charting-by-exception format.

What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

2. The antibiotics the patient has received are not strong enough to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

Which patients are at high risk for nutritional deficits? (Select all that apply.) 1. The divorced computer programmer who eats precooked food from the local restaurant 2. The middle-age female with celiac disease who does not follow her gluten-free diet 3. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements 5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

2. The middle-age female with celiac disease who does not follow her gluten-free diet 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter.

2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions.

In addition to an adequate patient assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? 1. The family has provided permission. 2. The patient has provided permission and consent. 3. The health care provider has given approval or provided orders for the therapy. 4. He or she has documented that the patient has a complete understanding of complementary and alternative medicine.

2. The patient has provided permission and consent.

The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.

2. The patient may be requesting a private room to facilitate an intimate relationship with his partner.

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient? 1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-through gait

2. Three-point gait

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2. Toileting. 3. Bathing. 5. Eating.

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm, incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Indirect lighting to reduce glare

2. Use of warm, incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies

Traditional Chinese medicine (TCM) is used by many patients. Which statement most accurately describes intervention(s) offered by TCM providers? 1. Uses acupuncture as its primary intervention modality 2. Uses many modalities based on the individual's needs 3. Uses primarily herbal remedies and exercise 4. Is the equivalent of medical acupuncture

2. Uses many modalities based on the individual's needs

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.) 1. If patient is standing, attempt to get him or her back in bed. 2. With patient on floor, clear surrounding area of furniture or equipment. 3. If possible, keep patient lying supine. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

2. With patient on floor, clear surrounding area of furniture or equipment. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) 1. Sexual issues are expected in a woman this age. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. It is not unusual for medical conditions such as cancer to contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning.

2. Women experience sexual dysfunction more frequently than men. 4. It is not unusual for medical conditions such as cancer to contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning.

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data validation 4. Termination

2. Working phase

On average, nursing handovers occur ___ times a day for each patient.

3

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the correct order: 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support.

3, 1, 2, 5, 6, 4 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. 4. Check time elapsed.

Using the Transtheoretical Model of Change, order the steps that a patient goes through to make a lifestyle change related to physical activity. 1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school. 2. Eight months after beginning walking, the individual participates with his wife in a local 5K race. 3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lbs. 4. The individual walks 2 to 3 miles, 5 nights a week, with his wife. 5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan.

3, 1, 5, 4, 2 3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lbs. 1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school. 5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan. 4. The individual walks 2 to 3 miles, 5 nights a week, with his wife. 2. Eight months after beginning walking, the individual participates with his wife in a local 5K race.

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order. 1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly. 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 5. Assess condition of skin where restraint will be placed.

3, 4, 1, 5, 2 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 1. Be sure that patient is comfortable with arm in anatomic alignment. 5. Assess condition of skin where restraint will be placed. 2. Wrap wrist with soft part of restraint toward skin and secure snugly.

How much should a patient drink each day?

3-4 L/day or 0.502/lb of body weight

A nursing assistive personnel asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? 1. "As long as we use proper body mechanics, no one will get hurt." 2. "The patient only weighs 125 lbs. You don't need my assistance." 3. "Call the lift team for additional assistance." 4. "The two of us can lift the patient easily."

3. "Call the lift team for additional assistance."

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, stop smoking? I've been smoking since I was 16!" 1. "That's fine. Some people who smoke live a long life." 2. "OK. I want you to decrease the number of cigarettes you smoke by one each day, and I'll see you in 1 month." 3. "I understand. Can you think of the greatest reason why stopping smoking would be challenging for you?" 4. "I'd like you to attend a smoking cessation class this week and use nicotine replacement patches as directed."

3. "I understand. Can you think of the greatest reason why stopping smoking would be challenging for you?"

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? 1. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." 2. "Sleep medicines won't cause any sleep problems once I stop taking them." 3. "I'll talk to my health care provider before I use an over-the-counter sleep medication." 4. "I'll contact my health care provider if I feel extremely sleepy in the mornings."

3. "I'll talk to my health care provider before I use an over-the-counter sleep medication."

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

3. "It takes me about 45 to 60 minutes to fall asleep."

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care."

3. "Only people who are dying can receive palliative care."

The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? 1. "Tell me where you are." 2. "What can you tell me about your illness?" 3. "Repeat these numbers back to me: 7...5...8." 4. "What does this mean: 'A stitch in time saves nine?'"

3. "Repeat these numbers back to me: 7...5...8."

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident."

3. "Tell me what happened before, during, and after the automobile accident tonight."

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how overeating affects their health."

3. "You have four children; do you have any concerns about going home and caring for them?"

A 17-year-old girl asks for more information about birth control methods and says that she does not want her parents to know she is using birth control. The nurse informs the patient that the most effective option for her situation would be: 1. An effective long-term method such as a subdermal implant. 2. A hormonal method such as birth control pills or the transdermal patch. 3. A long-acting hormonal injection given every 12 weeks. 4. Abstinence during her most fertile time.

3. A long-acting hormonal injection given every 12 weeks.

Which activity shows a nurse engaged in primary prevention? 1. A home health care nurse visits a patient's home to change a wound dressing. 2. A nurse is assessing risk factors of a patient in the emergency department admitted with chest pain. 3. A school health nurse provides a program to the first-year students on healthy eating. 4. A nurse schedules a patient who had a myocardial infarction for cardiac rehabilitation sessions weekly.

3. A school health nurse provides a program to the first-year students on healthy eating.

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.

3. Advance the catheter to the bifurcation of the drainage and balloon ports.

A cardiac nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but doesn't feel comfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge 2. Avoid discussing the topic unless the patient brings it up 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training in the near future on how to discuss such issues 5. Encourage the patient to discuss any personal concerns with the cardiologist

3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training in the near future on how to discuss such issues

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1. Contact the nursing supervisor. 2. Restrict the family's visiting privileges. 3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 5. Thank the family for being conscientious and put the four rails up. 6. Discuss alternatives that are appropriate for this patient with the family.

3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 6. Discuss alternatives that are appropriate for this patient with the family.

An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed? 1. Diagnosis 2. Evaluation 3. Assessment 4. Implementation

3. Assessment

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry

3. Clinical decision support system

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing.

3. Clinical inference.

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3. Collect one fecal smear from three separate bowel movements.

Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand

3. Decreased lung expansion

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?

3. Do you dribble urine constantly?

The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is appropriate to include on the plan? 1. Instruct the patient to sleep in a supine position. 2. Have patient limit fluid intake 2 hours before bedtime. 3. Elevate head of bed and assume a side or prone position. 4. Encourage patient to take an over-the-counter sleep aid.

3. Elevate head of bed and assume a side or prone position.

What is the palliative care team's primary obligation for the patient with severe pain? 1. Providing postmortem care. 2. Teaching about grief stages. 3. Enhancing the patient's quality of life. 4. Supporting the family after the death.

3. Enhancing the patient's quality of life.

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. Explain the reasons for isolation procedures and provide meaningful stimulation.

An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? 1. Talk to the patient at a distance so he or she may read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so the light is on his or her face when speaking.

3. Face the patient when speaking; demonstrate ideas you wish to convey.

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: 1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. 2. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. 3. Gives a newly ordered medication before entering the order in the patient's medical record. 4. Asks the preceptor to listen in on the phone conversation.

3. Gives a newly ordered medication before entering the order in the patient's medical record.

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? ​ 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair.

3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 2. Walk at a relaxed pace. 1. Tell patient when you are approaching the chair. 5. Position patient's hand on back of chair.

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows all hospital staff access to your medical record. 2. HIPAA limits the information that is documented in your medical record. 3. HIPAA provides you with greater protection of your personal health information. 4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

3. HIPAA provides you with greater protection of your personal health information

What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations

3. Hand hygiene practices

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.

3. Have the patient relax the foot while lying supine. 5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Are your bowel movements soft and formed? 3. Have you experienced frequent, small liquid stools recently? 4. Have you taken antibiotics recently?

3. Have you experienced frequent, small liquid stools recently?

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) 1. Improved health among the staff 2. Increased patient safety 3. Improved staff satisfaction 4. Improved staff relationships 5. Fewer overtime assignments

3. Improved staff satisfaction 4. Improved staff relationships

Nurses in an acute care hospital are attending a unit-based education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education? 1. Continuing education 2. Graduate education 3. In-service education 4. Professional Registered Nurse Education

3. In-service education

What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment? 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks 2. Use diapers and heavy padding on the bed 3. Initiate bowel or habit training program to promote continence 4. Help the patient to toilet once every hour

3. Initiate bowel or habit training program to promote continence

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine

3. Light pink urine

Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply.) 1. Keep the knees in a locked position. 2. Bend at the waist to maintain a center of gravity. 3. Maintain a wide base of support. 4. Hold objects away from the body for improved leverage. 5. Encourage patient to help as much as possible.

3. Maintain a wide base of support. 5. Encourage patient to help as much as possible.

While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? 1. Disease, spirit, and family interactions 2. Desires and emotions of the patient 3. Mind-body-spirit of patients and their families 4. Muscles, nerves, and spine disorders

3. Mind-body-spirit of patients and their families

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? 1. Spiritual Distress related to questioning God 2. Hopelessness related to terminal diagnosis 3. Pain related to disease process 4. Anticipatory Grief related to impending death

3. Pain related to disease process

A nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for guided imagery? 1. Pregnant patient 2. Hypertensive patient 3. Patient with post-traumatic stress disorder (PTSD) 4. A pediatric patient

3. Patient with post-traumatic stress disorder (PTSD)

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? 1. Rip the papers up into small pieces and place the pieces into a standard trash can 2. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit 3. Place papers with patient information in a secure canister marked for shredding 4. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

3. Place papers with patient information in a secure canister marked for shredding

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

A patient registered at the local fitness center and purchased a pair of exercise shoes. The patient is in what stage of behavioral change? 1. Precontemplation 2. Contemplation 3. Preparation 4. Action

3. Preparation

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus

3. Pressure ulcers

Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) 1. Massage therapy 2. Traditional Chinese medicine 3. Progressive relaxation 4. Breathwork and guided imagery 5. Therapeutic touch

3. Progressive relaxation 4. Breathwork and guided imagery

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? 1. Reminiscence 2. Validation therapy 3. Reality orientation 4. Body image interventions

3. Reality orientation

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3. Report the time and amount of first voiding.

Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association advocates which of the following? 1. Mandate that physical therapists do all patient transfers 2. Require adequate staffing levels in health care organizations 3. Require the use of assistive equipment and devices 4. Require an adequate number of staff to be involved in all patient transfers

3. Require the use of assistive equipment and devices

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

3. Respiratory rate of 8 breaths/min

Which nursing intervention is most important when caring for a patient with an ileostomy? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting or cutting a pouch with an appropriate-size stoma opening 4. Wearing sterile gloves while caring for the stoma

3. Selecting or cutting a pouch with an appropriate-size stoma opening

The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? 1. Rapid eye movement (REM) sleep 2. Stage 1 nonrapid eye movement (NREM) sleep 3. Stage 4 NREM sleep 4. Transition period from NREM to REM sleep

3. Stage 4 NREM sleep

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? 1. Supine with both arms overhead with palms upward 2. Sitting with hands clasped just above the umbilicus 3. Supine with the right arm abducted and hand under the head and neck 4. Lying on the right side, adducting the right arm on the side of the body

3. Supine with the right arm abducted and hand under the head and neck

Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: 1. Avoid activities in which there may be crowds. 2. Delay childhood immunizations until hearing can be verified. 3. Take precautions when involved in activities associated with high-intensity noises. 4. Prophylactically administer antibiotics to reduce the incidence of infections.

3. Take precautions when involved in activities associated with high-intensity noises.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better

3. Talk with the preceptor or manager and ask for assistance in handling this issue

A nurse meets with the registered dietitian and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

3. Teamwork and collaboration

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches begin. 4. Uh huh, tell me more.

3. Tell me what makes your headaches begin.

A patient had surgery for a total knee replacement a week ago and is currently participating in daily physical rehabilitation sessions at the surgeon's office. In what level of prevention is the patient participating? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Quaternary prevention

3. Tertiary prevention

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 lbs. 2. The patient speaks and understands English. 3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation. 4. The patient received analgesia for pain 30 minutes ago.

3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.

A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? 1. The patient keeps the cane on the left side of the body. 2. The patient slightly leans to one side while walking. 3. The patient keeps two points of support on the floor at all times. 4. After the patient places the cane forward, he or she then moves the right leg forward to the cane.

3. The patient keeps two points of support on the floor at all times.

Which statement best describes the evidence associated with complementary therapies as a whole? 1. Many clinical trials in complementary therapies support their effectiveness in a wide range of clinical problems. 2. It is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use. 3. The science supporting the effectiveness of complementary therapies is early in its development. 4. Most of the research examining complementary and alter​native therapies has found little evidence, suggesting that, although people like them, they are not effective.

3. The science supporting the effectiveness of complementary therapies is early in its development.

The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

3. Unstageable

Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia? 1. Ask open-ended questions 2. Speak to the patient as if he or she is a child 3. Use a dry-erase board or paper and pen for writing messages 4. Avoid the use of gestures and other nonverbal forms of communication

3. Use a dry-erase board or paper and pen for writing messages

A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse

3. Use a professional interpreter to provide wound care education in Spanish

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place

3. Washing with soap and water before applying the condom-type catheter

During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? 1. Nodule 2. Macule 3. Wheal 4. Pustule

3. Wheal

A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing.

4, 2, 1, 3 4. Use aseptic technique to change the dressing. 2. Reassure the patient and recheck the wound later. 1. Notify the health care provider of the patient's status. 3. Support the patient's fluid and nutritional needs.

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place waterproof bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1 4. Place waterproof bag near bed. 3. Fill syringe with irrigation fluid. 2. Attach 19-gauge angiocatheter to syringe. 5. Position angiocatheter over wound. 1. Use slow, continuous pressure to irrigate wound.

A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed? 1. "I am at risk for injury from temperature extremes." 2. "I may be able to dress more easily with zippers or pullover sweaters." 3. "A home care nurse may help me figure out how to be more independent." 4. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

4. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

Which statement made by the patient indicates a need for further teaching on sleep hygiene? 1. "I'm going to do my exercises before I eat dinner." 2. "I'm going to go to bed every night at about the same time." 3. "I set my alarm to get up at the same time every morning." 4. "I moved my computer to the bedroom so I could work before I go to sleep."

4. "I moved my computer to the bedroom so I could work before I go to sleep."

Which statement made by the patient indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a computed tomography (CT) colonoscopy every 5 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 50."

4. "I'll make sure to have a fecal occult blood test annually once I turn 50."

Which of the following documentation entries is most accurate? 1. "Patient walked up and down hallway with assistance, tolerated well." 2. "Patient up, out of bed, walked down hallway and back to room, tolerated well." 3. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." 4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? 1. "The patient has a defiant attitude and is demanding test results." 2. "The patient appears to be upset with the nurse because he wants his test results immediately." 3. "The patient is demanding and is complaining about the doctor." 4. "The patient stated feelings of frustration from the lack of information received regarding test results."

4. "The patient stated feelings of frustration from the lack of information received regarding test results."

A nursing professor is teaching a nursing student about caring patients who use herbal preparations in addition to prescribed medications. Which of the following statements made by the student indicates that the student understands herbal preparations? 1. "Herbal preparations are regulated by the Food and Drug Administration (FDA); therefore I need to tell patients that they are completely safe." 2. "They are natural products and therefore are safe as long as you use them for the conditions that are indicated." 3. "These preparations are covered by insurance, including Medicare, Medicaid, and private payers." 4. "We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

4. "We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format 3. Back channeling 4. A problem-oriented approach

4. A problem-oriented approach

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? 1. When the sexual partner passes away, the survivor no longer feels sexual. 2. A decrease in an older adult's libido occurs. 3. Any outward expression of sexuality suggests that the older adult is having a developmental problem. 4. All older adults, whether healthy or frail, need to express sexual feelings.

4. All older adults, whether healthy or frail, need to express sexual feelings.

Meditation may compound the effects of which of these medications? 1. Prednisone and antibiotics 2. Insulin and vitamins 3. Cough syrups and aspirin 4. Antihypertensive and thyroid-regulating medications

4. Antihypertensive and thyroid-regulating medications

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? 1. Lupus and diabetes 2. Ulcers and hepatitis 3. Heart disease and pancreatitis 4. Chronic back pain and arthritis

4. Chronic back pain and arthritis

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4. Cleansed wound

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code? 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong to provide patient care

4. Defines the principles of right and wrong to provide patient care

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? 1. "Avoid rushing when documenting an entry in the medical record." 2. "Use correction fluid to remove the entry." 3. "Draw a single line through the statement and initial it." 4. Enter only objective and factual information about a patient in the medical record.

4. Enter only objective and factual information about a patient in the medical record.

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation

4. Evaluation

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Physical changes usually do not affect sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4. Frequency and opportunities for sexual activity may decline.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern

4. Health perception-health management pattern

A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility

4. Humility

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

4. Informatics

Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4. Lactose intolerance

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness

4. Left ankle joint stiffness

The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? 1. Clinical nurse specialist 2. Nurse administrator 3. Nurse educator 4. Nurse researcher

4. Nurse researcher

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity 2. Opioid tolerance 3. Opioid addiction 4. Opioid withdrawal

4. Opioid withdrawal

A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contaminated equipment or material.

4. Perform hand hygiene after care and/or handling contaminated equipment or material.

The examination for registered nurse (RN) licensure is exactly the same in every state in the United States. This examination: 1. Guarantees safe nursing care for all patients. 2. Ensures standard nursing care for all patients. 3. Ensures that honest and ethical care is provided. 4. Provides a minimal standard of knowledge for an RN in practice.

4. Provides a minimal standard of knowledge for an RN in practice.

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

The nurse is administering a benzodiazepine sleep aid to an older adult. What should be the priority assessment for the patient? 1. Incontinence 2. Nausea and vomiting 3. Bradycardia 4. Respiratory depression

4. Respiratory depression

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity Intolerance 2. Impaired Bed Mobility 3. Acute Pain 4. Risk for Falls

4. Risk for Falls

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? 1. Health perception-health management pattern 2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Self-perception-self-concept pattern

4. Self-perception-self-concept pattern

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? 1. Using silence 2. Asking, "Why are you crying today?" 3. Using therapeutic touch 4. Stating, "I see that you're crying."

4. Stating, "I see that you're crying."

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat 2. Turn her on their side 3. Put on oxygen at 2-L nasal cannula 4. Stop feeding her and place on NPO

4. Stop feeding her and place on NPO

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? 1. TENS works by causing distraction. 2. TENS therapy does not require a health care provider's order. 3. TENS requires an electrical source for use. 4. TENS electrodes are applied near or directly on the site of pain.

4. TENS electrodes are applied near or directly on the site of pain.

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? 1. Tell the student that temporary confusion is normal and simply requires reorientation 2. Tell the student to increase the patient's fluid intake since the urine is concentrated 3. Tell the student that her assessment findings are normal for an older adult 4. Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

4. Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture Rationale: delirium is typically the first symptom of systemic infections (in this case, UTI from catheter)

A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome related to using this additional modality? 1. To eat less food 2. To control diabetes 3. To live longer with acquired immunodeficiency syndrome (AIDS) 4. To learn how to control some autonomic nervous system responses

4. To learn how to control some autonomic nervous system responses

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? 1. Only infants and toddlers need to ride in the back seat. 2. All toddlers can move to a forward facing car seat when they reach age 2. 3. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. 4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: 1. Gastric motility, thereby facilitating glucose digestion. 2. Respiratory effort, thereby decreasing activity intolerance. 3. Overall cardiac output, thereby resuming resting heart rate. 4. Use of glucose and fatty acids, thereby decreasing blood glucose level.

4. Use of glucose and fatty acids, thereby decreasing blood glucose level.

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

4. Use of incentive spirometer every 2 hours while awake

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

4. When 75% of the patient's nutritional needs are met by the tube feedings

The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? 1. Encourage the patient to rearrange her home furnishings regularly to keep active. 2. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility. 3. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. 4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment

4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment

Approximately ___ of adult Americans use some form of CAM each year.

40%

What percent of HCAI are UTIs?

40%

If bowel sounds are "absent" during abdominal auscultation, how long should you listen to each quadrant?

5 minutes each

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9 5. Drape patient with the sterile square and fenestrated drapes. 7. Prepare sterile field and supplies. 2. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 1. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 3. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

Place the steps for an ostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1 5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 1. Close the end of the pouch.

How many days out of a 28-day cycle can a woman get pregnant (is fertile)?

5-6 days out of the cycle

Place the steps to administering a prepackaged enema the correct order. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6, 4, 3, 1, 5, 2 6. Explain procedure to the patient. 4. Perform hand hygiene and apply clean gloves. 3. Position patient on side. 1. Insert enema tip gently in the rectum. 5. Squeeze contents of container into rectum. 2. Help patient to bathroom when he or she feels urge to defecate.

A nurse has the responsibility of managing a deceased patient's postmortem care. What is the proper order for postmortem care? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

6, 9, 2, 5, 7, 3, 1, 4, 8 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 9. Elevate the head of the bed. 2. Collect any needed specimens. 5. Speak to the family members about their possible participation. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 3. Remove all tubes and indwelling lines. 1. Bathe the body of the deceased. 4. Position the body for family viewing. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control.

Vitals: Pulse

60 - 100 bpm

What is stage 1 hypertension?

>140/>90

What is stage 2 hypertension?

>160/>90

Vitals: Pulse Ox

>95%

What is adjuvant analgesic?

A drug that has a primary purpose other than pain relief but can also serve as an analgesic for some painful conditions

What is biophilia?

A hypothesis that humans have an innate tendency/are hardwired to seek connections with nature and other forms of life.

What is a hoyer lift?

A machine-controlled sling that helps to transfer heavier patients

What is allodynia?

A nonpainful stimulus felt as painful in spite of normal appearing tissues

What is a nursing handover?

A nursing handover occurs when one nurse hands over the responsibility of care for a patient to another nurse, for example, at the end of a nursing shift.

What is addiction?

A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.

What is a therapeutic relationship?

A relationship between a patient and a nurse that is goal-directed, patient-centered, and objective

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) A. "I am thinking about joining the health committee at my church." B. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." C. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." D. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." E. "I will go back to school as soon as I finish orientation."

A. "I am thinking about joining the health committee at my church." B. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." C. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

According to the "Life Behaviors of a Sexually Healthy Adult", a sexually healthy adult will (select all that apply): A. Appreciate one's own body B. Exhibit skills that enhance personal relationships C. Be involved in one relationship D. Enjoy and express one's sexuality throughout life E. Interact with all genders in respectful and appropriate ways

A. Appreciate one's own body B. Exhibit skills that enhance personal relationships D. Enjoy and express one's sexuality throughout life E. Interact with all genders in respectful and appropriate ways

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? A. Call the nursing supervisor to discuss the situation B. Discuss the problem with a colleague C. Leave the nursing unit and go home D. Say nothing and begin your work

A. Call the nursing supervisor to discuss the situation

Which vertebrae are concave? A. Cervical B. Thoracic C. Lumbar D. Sacrococcygeal

A. Cervical C. Lumbar

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) A. Failure to document a change in assessment data B. Failure to provide discharge instructions C. Failure to follow the six rights of medication administration D. Failure to use proper medical equipment ordered for patient monitoring E. Failure to notify a health care provider about a change in the patient's condition

A. Failure to document a change in assessment data E. Failure to notify a health care provider about a change in the patient's condition

An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea? A. Fever increases metabolic demands, requiring increased oxygen need. B. Blood glucose stores are depleted and the cells do not have energy to use oxygen. C. Carbon dioxide production increases due to hyperventilation. D. Carbon dioxide production decreases due to hypoventilation.

A. Fever increases metabolic demands, requiring increased oxygen need.

Your patient comes in for her annual wellness checkup and upon assessment, you conclude that the patient is presenting signs of abuse. Which of the following are signs of abuse (select all that apply)? A. Flinching B. Bruises in different stages of healing C. Warm skin D. Breath sounds WNL

A. Flinching B. Bruises in different stages of healing

What constitutes a heart-healthy diet (select all that apply)? A. High fiber B. Low sodium C. Low sugar D. High in saturated fat

A. High fiber B. Low sodium C. Low sugar

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? A. How to use an inhaler during an asthma attack B. The need to avoid people who smoke to prevent asthma attacks C. Where to purchase a medical alert bracelet that says she has asthma D. The importance of maintaining a healthy diet and exercising regularly

A. How to use an inhaler during an asthma attack

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? A. Raise the head of the bed to 45 degrees or higher. B. Get the oxygen saturation with a pulse oximeter. C. Take the blood pressure and respiratory rate. D. Notify the health care provider of the shortness of breath.

A. Raise the head of the bed to 45 degrees or higher.

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A. Record the amount and continue to monitor drainage. B. Notify the physician. C. Strip the chest tube starting at the chest. D. Increase the suction by 10 mm Hg.

A. Record the amount and continue to monitor drainage.

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply.) A. Sharp pleuritic pain that worsens on inspiration B. Crackles over lung bases of affected lung C. Tracheal deviation toward the affected lung D. Worsening dyspnea E. Absent lung sounds to auscultation on affected side

A. Sharp pleuritic pain that worsens on inspiration D. Worsening dyspnea E. Absent lung sounds to auscultation on affected side

In normal patients, gait is (select all that apply): A. Smooth B. Effortless C. Step length is about 15 inches from heel to heel D. Uneven

A. Smooth B. Effortless C. Step length is about 15 inches from heel to heel

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) A. SpO​2​ levels B. Amount, color, and consistency of sputum production C. Fluid status D. Change in respiratory rate and pattern E. Pain in lower leg

A. SpO​2​ levels B. Amount, color, and consistency of sputum production D. Change in respiratory rate and pattern

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) A. Taking or selling controlled substances B. Refusing to provide health care information to a patient's child C. Reporting suspected abuse and neglect of children D. Applying physical restraints without a written physician's order E. Completing an occurrence report on the unit

A. Taking or selling controlled substances D. Applying physical restraints without a written physician's order

Which group of individuals are at a high risk for sexual assault? A. Young women B. Individuals in long-term care C. Late night/overnight workers D. College students

A. Young women

The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? A: "Health problems such as diabetes, COPD, and hypertension have little effect on sexual functioning and desire" B: "It usually takes longer for both sexes to reach an orgasm" C: "Most of the normal changes in function are related to alteration in circulation and hormone levels" D: "Many medications can interfere with sexual function"

A: "Health problems such as diabetes, COPD, and hypertension have little effect on sexual functioning and desire"

The nurse is providing education on STIs to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) A: "I don't need to use condoms since there is no risk for pregnancy" B: "I should be screened for an STI each time I'm with a new partner" C: "I know I'm not infected because I don't have discharge or sores" D: "I was tested for STIs last year so I know I'm not infected" E: "The infection rate in older adults is low because most are not sexually active"

A: "I don't need to use condoms since there is no risk for pregnancy" C: "I know I'm not infected because I don't have discharge or sores" D: "I was tested for STIs last year so I know I'm not infected" E: "The infection rate in older adults is low because most are not sexually active"

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (NP) informs her that she will be screening her for STIs. The patient replies, "I know I don't have an STI because I don't have any symptoms." How should the NP respond? (Select all that apply.) A: "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." B: "Bacterial STIs don't usually cause symptoms, but you could have an asymptomatic viral STI." C: "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." D: "People between the ages of 15 and 24 have the highest incidence of STIs." E: "There is no need to screen for infection since you aren't having any problems."

A: "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." C: "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." D: "People between the ages of 15 and 24 have the highest incidence of STIs."

Which of the following are examples of problems with the health care system that contribute to health disparities? (Select all that apply.) A: A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for missed visits B: The discharge nurse at a hospital uses Teach Back with a patient to ensure that she has communicated the discharge instructions clearly C: A community hospital lacks an adequate staff of social workers who are able to ensure patients' access to resources they need to take care of their health D: A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow-up appointment E: A nurse uses a family member as an interpreter to explain the patient's medications F: The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities

A: A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for missed visits C: A community hospital lacks an adequate staff of social workers who are able to ensure patients' access to resources they need to take care of their health D: A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow-up appointment E: A nurse uses a family member as an interpreter to explain the patient's medications F: The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities

The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) A: Adolescents often explore their sexual identity and expose themselves to complications such as STIs or unplanned pregnancy B: Peer approval and acceptance are not important in this age-group C: Lesbian, gay, bisexual and transgender (LGBT) youth often experience stress from identification with a sexual minority group D: Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety E: Adolescence is a time of emotional stability and self-acceptance

A: Adolescents often explore their sexual identity and expose themselves to complications such as STIs or unplanned pregnancy C: Lesbian, gay, bisexual and transgender (LGBT) youth often experience stress from identification with a sexual minority group D: Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety

A concern for the welfare and well-being of others. In professional practice, it is reflected by the nurse's concern and advocacy for the welfare of patients, other nurses, and other healthcare providers. A: Altruism B: Autonomy C: Human dignity D: Integrity E: Social justice

A: Altruism

What is the nursing process (ADPIE)?

A: Assessment D: Diagnosis P: Planning/Prevention I: Intervention/Implementation E: Evaluation

In Hinduism, when an individual dies, it is believed that although the physical body is gone, the deceased's _____________ body will remain as close to them as ever. A: Astral B: Spiritual C: Celestial D: Physical

A: Astral

Moral/ethical principle: A patient's right to self-determination without outside control; assumes rational thinking on the part of the individual; challenged when rights of others infringed upon by individual. A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

A: Autonomy

Which two moral/ethical principles are most important? A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

A: Autonomy C: Non-maleficence *Autonomy and non-maleficence seen as preeminent because they emphasize respect for the person and avoidance of harm

The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question asked by the nurse demonstrates a nonjudgemental attitude? A: Can you tell me about your sexual orientation? B: How do you and your wife feel about intimacy? C: Do you have sex with men, women, or both? D: Do you have sexual intercourse at your age?

A: Can you tell me about your sexual orientation?

Which factors influence a person's approach to death? (Select all that apply.) A: Culture B: Age C: Spirituality D: Personal beliefs E: Previous experiences with death F: Gender G: Level of education H: Degree of social support

A: Culture C: Spirituality D: Personal beliefs E: Previous experiences with death H: Degree of social support

Models/theories of ethical reasoning: Right or wrong based on duty/obligation; does not look at consequences of action; individual has clear direction in how to act in all situations. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

A: Deontological

The socialization process into one's primary culture; also known as socialization. A: Enculturation B: Acculturation C: Assimilation D: Ethnocentrism

A: Enculturation

Which of the following changes can help create a more inclusive environment for lesbian, gay, bisexual, and transgender (LGBT) patients? (Select all that apply.) A: Explicitly including sexual orientation and gender identity into nondiscrimination policies B: Displaying art that reflects LGBT community C: Modifying health care forms to provide opportunities for gender identity and sexual orientation disclosure D: Not asking patients about their gender identity and sexual orientation to avoid making them uncomfortable E: Ensuring access to unisex or single-stall bathrooms

A: Explicitly including sexual orientation and gender identity into nondiscrimination policies B: Displaying art that reflects LGBT community C: Modifying health care forms to provide opportunities for gender identity and sexual orientation disclosure E: Ensuring access to unisex or single-stall bathrooms

Which skin-care measures are used to manage a patient who is experiencing fecal and/or oral incontinence? (Select all that apply.) A: Frequent position changes B: Keeping the buttocks exposed to air at all times C: Using a large absorbent diaper, changing when saturated D: Using an incontinence cleaner E: Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel F: Applying a moisture barrier ointment

A: Frequent position changes D: Using an incontinence cleaner F: Applying a moisture barrier ointment

Complication of wound healing: External or internal. 24-48 hours after injury. A: Hemorrhage B: Infection C: Dehiscence D: Evisceration

A: Hemorrhage

Which of the following are considered social determinants of health? (Select all that apply.) A: Lack of primary health care providers in a zip code B: Poor-quality public school education that prevents a person from developing adequate reading skills C: Lack of affordable health insurance D: Employment opportunities that do not provide paid vacation or sick leave E: The number of times a person exercises during a week F: Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home

A: Lack of primary health care providers in a zip code B: Poor-quality public school education that prevents a person from developing adequate reading skills C: Lack of affordable health insurance D: Employment opportunities that do not provide paid vacation or sick leave F: Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home

An obligation that has been incurred or might incur through any act or failure to act. A: Liability B: Negligence C: Malpractice

A: Liability

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? A: Normal B: Complicated C: Chronic D: Disenfranchised

A: Normal

A 42-year old sexually active female is being assessed by a nurse during her annual physical. The woman states that she has not had a period for the last 2 months. The nurse knows that the most likely cause of this occurrence is: A: Pregnancy B: Illicit drug use C: Chlamydia infection D: Early-onset menopause

A: Pregnancy

To assist a patient in the grieving process, which of the following is most helpful to determine? A: Previous experiences with grief and loss B: Religious affiliation and denomination C: Ethnic background and cultural practices D: Current financial status

A: Previous experiences with grief and loss

When planning care for the dying patient, which interventions promote the patient's dignity? (Select all that apply). A: Providing respect B: Viewing patients as a whole C: Providing symptom management D: Showing interest E: Being present F: Using a preferred name

A: Providing respect B: Viewing patients as a whole D: Showing interest E: Being present F: Using a preferred name

How can a nurse work on developing cultural awareness? (Select all that apply.) A: Reflect on his or her past learning about health, illness, race, gender, and sexual orientation B: Develop greater self-knowledge about personal biases C: Recognize consciously the multiple factors that influence his or her own world view D: Engage in an in-depth self-examination of his or her own background E: Learn as many facts as possible about an ethnic group

A: Reflect on his or her past learning about health, illness, race, gender, and sexual orientation B: Develop greater self-knowledge about personal biases C: Recognize consciously the multiple factors that influence his or her own world view D: Engage in an in-depth self-examination of his or her own background

Drainage classification: Clear, watery plasma. A: Serous B: Purulent C: Serosanguineous D: Sanguineous

A: Serous

Stage the pressure ulcer: Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. A: Stage I B: Stage II C: Stage III D: Stage IV

A: Stage I

Stage the pressure ulcer: Skin is intact. When skin is pressed, it does not turn a lighter color (nonblanchable). Primary goal is to prevent skin breakage. A: Stage I B: Stage II C: Stage III D: Stage IV E: Unstageable

A: Stage I

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) A: Taking or selling controlled substances B: Refusing to provide health care information to a patient's child C: Reporting suspected abuse and neglect of children D: Applying physical restraints without a written physician's order E: Completing an occurrence report on the unit

A: Taking or selling controlled substances D: Applying physical restraints without a written physician's order

A grieving patient complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? A: They are normal symptoms of grief B: There is a need for pharmacological support for insomnia C: The patient is experiencing complicated grief D: These are common complaints of the admitted patient

A: They are normal symptoms of grief

A group has been overlooked in research and the design of interventions. A: Under inclusion B: Social inequality C: Social location

A: Under inclusion

What are the physical changes that occur as death approaches? (Select all that apply.) A: Unresponsiveness B: Erythema C: Mottling D: Restlessness E: Increased urine output F: Weakness G: Incontinence

A: Unresponsiveness C: Mottling D: Restlessness F: Weakness G: Incontinence

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) A: Use a transfer device (Ex: transfer board) B: Have head of bed elevated when transferring patient C: Have head of bed flat when repositioning patient D: Raise head of bed 60 degrees when patient positioned supine E: Raise head of bed 30 degrees when patient positioned supine

A: Use a transfer device (Ex: transfer board) C: Have head of bed flat when repositioning patient E: Raise head of bed 30 degrees when patient positioned supine

Type of normative ethics/morals that focus on the moral character of the agent; agent should have courage, generosity, compassion, etc. A: Virtue B: Deontological C: Consequential

A: Virtue

Changes to Skin: ABCD

A: asymmetry B: border irregularity C: color D: diameter (>6mm = bad)

What are some moral actions that are common moral principles?

AKA: universal principles -general statements about morally right/wrong, good/bad -do not murder -do not cause pain/suffering to others -prevent evil/harm -tell the truth

What is the most common surgical procedure in the United States?

Abortion

What is the action stage of behavioral change?

Actively engaged, lasts up to 6 months Implication: previous habits may prevent taking action relating to new behaviors; identify barriers and facilitators of change

ABCSP: Define A

Airway -speaking, stridor, vomiting

What are the core values of nursing?

Altruism, autonomy, human dignity, integrity, and social justice

What is the key goal with immobile patients?

Ambulate as much as possible

Example of nursing diagnosis statement

Anxiety related to situational crises and stress as evidenced by restlessness and insomnia -problem: anxiety -related factors: situational crises and stress -defining characteristics: restlessness and insomnia

What is the sequence for cardiac auscultation?

Aortic Pulmonic Erb's point Tricuspid Mitral

A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages on the basis of his blood sugar results. This type of activity addresses learning in the cognitive domain at the level of ​____________________.

Application

Vitals: Temperature

Average: 98.6°F - 100.4°F (36°C - 38°C) Oral/tympanic: 98.6°F Rectal: 99.5°F Axillary: 97.7°F

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: A. A teaching plan. B. A learning objective. C. Reinforcement of content. D. Enhancing the children's self-efficacy.

B. A learning objective.

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? A. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C. The patient cannot make changes in the advance directive once admitted to the hospital. D. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? A. Telling B. Analogy C. Demonstration D. Simulation

B. Analogy

In which abdominal area is it an immediate concern if bruits are heard here? A. Renal B. Aortic C. Femoral D. Iliac

B. Aortic

Which disease/infection is the most common in the United States? A. Syphilis B. Chlamydia C. Gonorrhea D. All are equal

B. Chlamydia

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? A. Simulation B. Demonstration C. Group instruction D. One-on-one discussion

B. Demonstration

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? A. Describing difficulties a family member has had in taking insulin B. Expressing the importance of learning the skill correctly C. Being able to see and understand the markings on the syringe D. Having the dexterity needed to prepare and inject the medication

B. Expressing the importance of learning the skill correctly

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A. Stimulates hyperventilation, causing respiratory alkalosis B. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs C. Stimulates hypoventilation, causing respiratory acidosis D. Causes alveoli to overinflate, leading to atelectasis

B. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy

B. Frequent change of position

Amanda's father passed away from a stoke a month ago. Amanda is having trouble focusing in class and often forgets to turn her assignments in. When her friends invite her out, she often declines. What is Amanda most likely experiencing? A. Abandonment B. Grief C. Withdrawal D. Lack of motivation

B. Grief

A patient presents with cold intolerance, myxedema, and bradycardia. Which disease process is the patient most likely experiencing? A. Diabetes B. Hypothyroidism C. Hyperthyroidism D. Stroke

B. Hypothyroidism

The nurse is organizing a disease prevention program for a specific cultural group. To effectively meet the needs of this group the nurse will: (Select all that apply.) A. Assess the needs of the community in general. B. Involve those affected by the problem in the planning process. C. Develop generalized goals and objectives for the program. D. Use educational materials that are simplistic and have many pictures. E. Assess commonly held health beliefs among the cultural group. F. Educate the specific cultural group about Western concepts of health and illness. G. Include cultural practices that are relevant to the specific community.

B. Involve those affected by the problem in the planning process. E. Assess commonly held health beliefs among the cultural group. G. Include cultural practices that are relevant to the specific community.

Which form of HPV is more common? A. Cervical B. Oral C. Anal

B. Oral

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) A. Information provided by the head nurse B. Policies and procedures of the employing hospital C. State Nurse Practice Act D. Regulations identified in The Joint Commission manual E. The American Nurses Association standards of nursing practice

B. Policies and procedures of the employing hospital C. State Nurse Practice Act D. Regulations identified in The Joint Commission manual E. The American Nurses Association standards of nursing practice

At which point of the lifespan do secondary sex characteristics begin to develop and self-stimulating behaviors become common? A. Adolescent B. School age C. Older Adult D. Infancy

B. School age

Many cranial nerves are impaired in which patient? A. Diabetics B. Stroke patients C. Teenagers D. All of the above

B. Stroke patients

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? A. Family member B. Surgeon C. Nurse D. Nurse manager

B. Surgeon

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) A. The nurse does not need any representation. B. The patient must prove injury, damage, or loss occurred. C. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. D. The patient must prove that a breach in the prevailing standard of care caused an injury. E. The burden of proof is always the responsibility of the nurse.

B. The patient must prove injury, damage, or loss occurred. C. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. D. The patient must prove that a breach in the prevailing standard of care caused an injury.

Which vertebrae are convex? A. Cervical B. Thoracic C. Lumbar D. Sacrococcygeal

B. Thoracic D. Sacrococcygeal

The nurse is planning to teach a patient about the important of exercise. When is the best time for teaching to occur (select all that apply)? A. When there are visitors in the room B. When the patient states that he or she is pain free C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life E. When the patient is being transported for a procedure

B. When the patient states that he or she is pain free C. Just before lunch, when the patient is most awake and alert

Sexual desire disorders are more common in which group of individuals? A. Men B. Women C. Children D. Equal in all

B. Women

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? A: "Only your family can read your medical record" B: "You have the right to read your record" C: "Patients are not allowed to read their records" D: "Only health care workers have access to patient records"

B: "You have the right to read your record"

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? A: A living will allows an appointed person the make health care decisions when the patient is in an incapacitated state B: A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state C: The patient cannot make changes in the advance directive once admitted to the hospital D: A durable power of attorney for health care is invoked only when the patient has terminal condition or is in a persistent vegetative state

B: A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state

The process by which a person learns to live in a second culture and adapt to that culture's practices and norms. A: Enculturation B: Acculturation C: Assimilation D: Ethnocentrism

B: Acculturation

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? A: Use therapeutic techniques when communicating with the patient B: Allow the patient to determine timing and scheduling of interventions C: Encourage family to only visit for short periods of time D: Provide the patient with a private room close to the nurse's station

B: Allow the patient to determine timing and scheduling of interventions

The right to self-determination. Professional practice reflects this when the nurse respects patients' rights to make decisions about their health care. A: Altruism B: Autonomy C: Human dignity D: Integrity E: Social justice

B: Autonomy

Moral/ethical principle: Duty to actively do good for patients. A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

B: Beneficence

A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (Select all that apply.) A: Always fail and cause illness and disease B: Cause negative responses over time C: React the same way for all individuals D: Protect an individual from harm in the short term

B: Cause negative responses over time D: Protect an individual from harm in the short term

What is the removal of devitalized tissue from a wound called? A: Pressure reduction B: Debridement C: Negative pressure wound therapy D: Sanitization

B: Debridement

Type of normative ethics/morals that focus on the act being performed as good/bad irrespective of the consequence; you should not do "bad" things even if the outcome would be positive. A: Virtue B: Deontological C: Consequential

B: Deontological

What may caregivers observe at the moment of death? (Select all that apply.) A: Mouth will be clamped closed B: Eyes will be still C: Heartbeat and breathing cease D: All muscles relax

B: Eyes will be still C: Heartbeat and breathing cease D: All muscles relax

Complication of wound healing: Common healthcare-associated infection (HCAI). Purulent drainage or positive culture. Fever, tenderness, pain, elevated WBC. A: Hemorrhage B: Infection C: Dehiscence D: Evisceration

B: Infection

The failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance. A: Liability B: Negligence C: Malpractice

B: Negligence

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice". What does the nurse tell the family member about palliative care? (Select all that apply.) A: Palliative care and hospice are the same thing B: Palliative care is for any patient, any time, any disease, in any setting C: Palliative care strategies are primarily designed to treat the patient's illness D: Palliative care relieves the symptoms of the illness and treatment E: Palliative care selects home health care services

B: Palliative care is for any patient, any time, any disease, in any setting D: Palliative care relieves the symptoms of the illness and treatment

A nurse is caring for a patient who recently had coronary bypass surgery and is now on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) A: Information provided by the head nurse B: Policies and procedures of the employing hospital C: State Nurse Practice Act D: Regulations identified in The Joint Commission manual E: The American Nurses Association standards of nursing practice

B: Policies and procedures of the employing hospital C: State Nurse Practice Act D: Regulations identified in The Joint Commission manual E: The American Nurses Association standards of nursing practice

When providing postmortem care, which action is a priority for the nurse? A: Locating the patient's clothing and personal belongings B: Providing culturally and religiously sensitive care in body preparation C: Providing postmortem care to protect the family of the deceased from having to view the body D: Transporting the body to the morgue as soon as possible

B: Providing culturally and religiously sensitive care in body preparation

Drainage classification: Thick, yellow, green, tan, or brown. A: Serous B: Purulent C: Serosanguineous D: Sanguineous

B: Purulent

What does the Braden Scale evaluate? A: Skin integrity at bony prominences, including any wounds B: Risk factors that place the patient at risk for skin breakdown C: The amount of repositioning that the patient can tolerate D: The factors that place the patient at risk for poor healing

B: Risk factors that place the patient at risk for skin breakdown

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at an increased risk for: (Select all that apply.) A: Heart disease B: Sepsis C: Pleural effusion D: Cardiac arrhythmias E: Diarrhea

B: Sepsis C: Pleural effusion D: Cardiac arryhthmias

The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) A: Nurses are not expected to discuss sexual issues with male patients and the physician should address this B: Sexual function can be affected negatively by some medications C: STIs can cause complications such as erectile dysfunction and screening should be done D: It is not unusual for men with health issues to experience erectile dysfunction E: Medications used to treat hypertension and depression seldom interfere with sexual function

B: Sexual function can be affected negatively by some medications D: It is not unusual for men with health issues to experience erectile dysfunction

Groups have unequal access to resources, services, and positions. A: Under inclusion B: Social inequality C: Social location

B: Social inequality

Stage the pressure ulcer: Shallow, open ulcer. Can be a blister with serous or serosanguineous fluid. Partial-thickness loss of epidermis. Red/pink wound bed. A: Stage I B: Stage II C: Stage III D: Stage IV E: Unstageable

B: Stage II

Stage the pressure ulcer: Full-thickness tissue loss; muscle and bone visible. May include undermining. A: Stage I B: Stage II C: Stage III D: Stage IV

B: Stage IV

Models/theories of ethical reasoning: Humanistic origins; outcome focused/ends justify the means. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

B: Teological

The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: A: The patient cannot be sexually active since he is moving into a nursing home B: The patient may be requesting a private room to facilitate an intimate relationship with his partner C: There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives D: Older adults in nursing homes usually do not participate in sexual activity

B: The patient may be requesting a private room to facilitate an intimate relationship with his partner

According to Healthy People 2020, certain ethnic groups in the US are disproportionately affected by STIs and HIV. What are the likely causes of this issue? (Select all that apply.) A: The large percentage of lesbian, gay, bisexual, or transgender individuals in the culture B: Values and expectations about sexual behavior by the men or women in the culture C: Religious beliefs and cultural attitudes toward the use of contraceptives D: Educational background and knowledge of health risks associated with sexual behaviors E: The higher incidence of sexual abuse in the affected ethnic groups

B: Values and expectations about sexual behavior by the men or women in the culture C: Religious beliefs and cultural attitudes toward the use of contraceptives D: Educational background and knowledge of health risks associated with sexual behaviors

A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) A: Sexual issue are expected in a women this age B: Women experience sexual dysfunction more frequently than men C: Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age D: It is not unusual for medical conditions such as cancer to contribute to HSDD E: Disturbances in self-concept affect sexual functioning

B: Women experience sexual dysfunction more frequently than men D: It is not unusual for medical conditions such as cancer to contribute to HSDD E: Disturbances in self-concept affect sexual functioning

What is healthcare economics?

Behavioral science that addresses how to allocate limited resources among unlimited demands and how to pay for these resources

What is Freud's psychoanalytical model?

Believed that adult personality is the result of how an individual resolves conflict between sources of pleasure and reality Stages -Oral: infancy (birth to 18 months) -Anal: early childhood/toddler (18 months to 3 years) -Phallic: preschool (3 to 5 years) -Latent: middle childhood (6 to 12 years) -Genital: adolescence (12 to 19 years)

Causes of urinary retention

Benign prostatic hyperplasia, opioids, anesthetics, beta-adrenergic blockers, neurologic injury

Types of UTIs: What is cystitis?

Bladder infection

What happens to the senses from a sensory overload?

Body stops receiving senses because too much stimulation

ABCSP: Define B

Breathing -skin color, spontaneous, chest movements

Gonorrhea and chlamydia primarily affect: A. 9-12 B. 13-18 C. 15-24 D. 20-30

C. 15-24

What is the most significant barrier to sexual expression among individuals in nursing care facilities? A. Old age B. Rules of facility C. Attitudes of nursing staff and family D. Decreased libido

C. Attitudes of nursing staff and family Any form of sexual behavior may be regarded as problematic

When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner? A. Printed pamphlets on cardiovascular disease and dietary recommendations from the American Heart Association B. A role-play activity requiring the patient to select proper foods from a wide selection C. Colored visual diagrams that categorize foods according to fat and sodium content D. A lecture-style discussion on heart healthy diet options

C. Colored visual diagrams that categorize foods according to fat and sodium content

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? A. Document her findings and treat the patient B. Instruct the mother on safe handling of a 2-year-old child C. Contact a child abuse hotline D. Discuss this story with a colleague

C. Contact a child abuse hotline

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up sputum occasionally B. Coughing up thin, watery sputum after nebulization C. Decreased ability to clear airway through coughing D. Lung sounds clear only after coughing

C. Decreased ability to clear airway through coughing

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? A. Patient Protection and Affordable Care Act (PPACA) B. Patient Self-Determination Act (PSDA) C. Health Insurance Portability and Accountability Act (HIPAA) D. Emergency Medical Treatment and Active Labor Act

C. Health Insurance Portability and Accountability Act (HIPAA)

A patient presents with tachycardia, weight loss, and mild tremors. Which disease process is the patient most likely experiencing? A. Diabetes B. Stroke C. Hyperthyroidism D. Hypothyroidism

C. Hyperthyroidism

Which of the following birth control methods are the most effective (select all that apply)? A. Pill B. Condoms C. IUD D. Implant E. Patch F. Cervical cap G. Diaphragm H. Vasectomy/Female sterilization I. Spermicide

C. IUD D. Implant H. Vasectomy/Female

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? A. Discussing patient conditions in the nursing report room at the change of shift B. Allowing nursing students to review patient charts before caring for patients to whom they are assigned C. Posting medical information about the patient on a message board in the patient's room D. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

C. Posting medical information about the patient on a message board in the patient's room

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Focus on knowledge the patient will need in a few weeks C. Provide only the information that the patient needs to go home D. Convince the patient that learning about her health is necessary

C. Provide only the information that the patient needs to go home

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A. The nurse's automobile insurance B. The nurse's homeowner's insurance C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence D. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence

A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: A. Latex condoms are the most effective way to eliminate the risk of HPV transmission. B. Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity. C. The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts. D. You are past the recommended age to receive the vaccine.

C. The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts.

According to our sexuality lecture, at what period of the lifespan do individuals "love to be nude"? A. Adolescent B. Older Adult C. Toddler/Preschool D. Infancy

C. Toddler/Preschool

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? A: "Even though you're continuing treatment, palliative care is something we might want to talk about." B: "Palliative care is appropriate for people with any diagnosis." C: "Only people who are dying can receive palliative care." D: "Children are able to receive palliative care."

C: "Only people who are dying can receive palliative care."

A 17-year-old girl asks for more information about birth control methods and says that she does not want her parents to know she is using birth control. The nurse informs the patient that the most effective option for her situation would be: A: An effective long-term method such as a subdermal implant B: A hormonal method such as birth control pills for the transdermal patch C: A long-acting hormonal injection given every 12 weeks D: Abstinence during her most fertile time

C: A long-acting hormonal injection given every 12 weeks

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? A: Yearning and searching B: Dysfunctional grief C: Anticipatory grief D: Denial

C: Anticipatory grief

A cardiac nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered an MI. The nurse knows that sexual issues are common after an MI but doesn't feel comfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) A: Instruct the patient to discuss any sexual concerns with his or her partner after discharge B: Avoid discussing the topic unless the patient brings it up C: Ask a more experienced nurse to cover this with the patient and learn from the example D: Plan to attend conferences or training in the near future on how to discuss such issues E: Encourage the patient to discuss any personal concerns with the cardiologist

C: Ask a more experienced nurse to cover this with the patient and learn from the example D: Plan to attend conferences or training in the near future on how to discuss such issues

The process by which a second culture's norms and practices displace a person's original cultural practices, languages, and beliefs. A: Enculturation B: Acculturation C: Assimilation D: Ethnocentrism

C: Assimilation

Type of normative ethics/morals that calls for doing whatever brings the best consequence or outcome no matter what the act. A: Virtue B: Deontological C: Consequential

C: Consequential

Complication of wound healing: Layers of skin and tissue separate. Obesity, increased pressure. A: Hemorrhage B: Infection C: Dehiscence D: Evisceration

C: Dehiscence

What is the palliative care team's primary obligation for the patient with severe pain? A: Providing postmortem care B: Teaching about grief stages C: Enhancing the patient's quality of life D: Supporting the family after the death

C: Enhancing the patient's quality of life

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? A: HIPAA allows all hospital staff access to your medical record B: HIPAA limits the information that is documented in your medical record C: HIPAA provides you with greater protection of your personal health information D: HIPAA enables health care institutions to release all of your personal information to improve continuity of care

C: HIPAA provides you with greater protection of your personal health information

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? A: Patient Protection and Affordable Care Act (PPACA) B: Patient Self-Determination Act (PSDA) C: Health Insurance Portability and Accountability Act (HIPAA) D: Emergency Medical Treatment and Active Labor Act

C: Health Insurance Portability and Accountability Act (HIPAA)

Respect for the inherent worth and uniqueness of individuals and populations. In professional practice, concern for this is reflected when the nurse values and respects all patients and colleagues. A: Altruism B: Autonomy C: Human dignity D: Integrity E: Social justice

C: Human dignity

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) A: Improved health among the staff B: Increased patient safety C: Improved staff satisfaction D: Improved staff relationships E: Fewer overtime assignments

C: Improved staff satisfaction D: Improved staff relationships

The behavior of a professional person's wrongful conduct, improper discharge of professional duties, or failure to meet the standard of care, which result in harm to another person. A: Liability B: Negligence C: Malpractice

C: Malpractice

While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? A: Disease, spirit, and family interactions B: Desires and emotions of the patient C: Mind-body-spirit of patients and their families D: Muscles, nerves, and spine disorders

C: Mind-body-spirit of patients and their families

Moral/ethical principle: Duty to prevent or avoid doing harm whether intentional or unintentional. A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

C: Non-maleficence

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? A: Spiritual distress related to questioning God B: Hopelessness related to terminal diagnosis C: Pain related to disease process D: Anticipatory grief related to impending death

C: Pain related to disease process

A nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for guided imagery? A: Pregnant patient B: Hypertensive patient C: Patient with PTSD D: Pediatric patient

C: Patient with PTSD

Models/theories of ethical reasoning: Based on principles of autonomy, beneficence, non-maleficence, and justice. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

C: Principlism

Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) A: Massage therapy B: Traditional Chinese medicine C: Progressive relaxation D: Breathwork and guided imagery E: Therapeutic touch

C: Progressive relaxation D: Breathwork and guided imagery

Drainage classification: Pale, pink, watery; mixture of clear and red fluid. A: Serous B: Purulent C: Serosanguineous D: Sanguineous

C: Serosanguineous

One's place in society is based on membership in a social group that determines access to resources. A: Under inclusion B: Social inequality C: Social location

C: Social location

Stage the pressure ulcer: Partial-thickness skin loss or intact blister with serosanguineous fluid. A: Stage I B: Stage II C: Stage III D: Stage IV

C: Stage II

Stage the pressure ulcer: Full-thickness tissue loss. May see subcutaneous fat. Sloughing may be present (shedding of cells). Eschar may be present (dry, dark scab - dead tissue). Possible undermining and tunneling. A: Stage I B: Stage II C: Stage III D: Stage IV E: Unstageable

C: Stage III

A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: A: Latex condoms are the most effective way to eliminate the risk of HPV transmission B: Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity C: The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts D: You are past the recommended age to receive the vaccine

C: The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts

When a patient dies, who is the best source of information for culturally sensitive assessment regarding customs and rituals surrounding death and grief? A: The patient's religious institution B: A search on the internet C: The patient's family D: A handbook on culturally sensitive care

C: The patient's family

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) A: The nurse does not need any representation B: The patient must prove injury, damage, or loss occurred C: The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred D: The patient must prove that a breach in the prevailing standard of care caused an injury E: The burden of proof is always the responsibility of the nurse

C: The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred D: The patient must prove that a breach in the prevailing standard of care caused an injury

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? A: Stage II B: Stage IV C: Unstageable D: Suspected deep-tissue damage

C: Unstageable

Chemoreceptors in the brain are sensitive to _______.

CO2

Complications of Wound Healing: Hemorrhage

Can be internal or external, greater risk 24-48 hours after injury

What is the most common reason that older adults have UTIs?

Catheters Other reasons: urinary retention, incontinence, pressure ulcers

_________________ sense changes in chemical content and stimulate neural regulators to adjust.

Chemoreceptors

ABCSP: Define C

Circulation -skin color, skin temperature, cap refill, obvious bleeding

What is cataracts?

Clouding of the lens in the eye that affects vision; related to aging

What is the basic component of a therapeutic relationship?

Communication

What does CAM stand for?

Complementary and alternative medicine

What is the contemplation stage of behavioral change?

Considering a change within the next 6 months Implication: ambivalence may be present, but pt is more likely to accept info

What is sustained fever?

Constant body temperature continuous above 100.4°F with little fluctuation

A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." C. "If I have trouble breathing at night, I'll use two or three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min.

D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min.

In which situation would the nurse need to report abuse? A. A 20-year-old claims that she recently got into an argument with her boyfriend and he hit her B. A man claims that his wife throws household items at him to inflict pain C. A geriatric patient has bruises on his arm that are in different stages of healing D. All of the above

D. All of the above THE NURSE IS OBLIGATED TO REPORT AT ANY SIGN OF ABUSE FOR ANY SITUATION

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A. Speaks loudly. B. Presents the information once. C. Expects the patient to understand the information quickly. D. Allows the patient time to express himself or herself and ask questions.

D. Allows the patient time to express himself or herself and ask questions.

At what period of the lifespan does sexuality begin? A. Adolescent B. Older Adult C. Infancy D. Before birth

D. Before birth

For which of the following health problems is a patient who has a 40-year history of smoking at risk? A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer

D. Cardiopulmonary disease and lung cancer

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness

D. Decreased activity tolerance and increased breathlessness

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? A. Give the family the record B. Discuss the issues that concern the family with them C. Call the nursing supervisor D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. Which type of content is the nurse providing? A. Simulation B. Restoring health C. Coping with impaired function D. Health promotion and illness prevention

D. Health promotion and illness prevention

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? A. Sonorous wheezes in the left lower lung B. Rhonchi mid sternum C. Crackles only in apex of lungs D. Inspiratory crackles in lung bases

D. Inspiratory crackles in lung bases

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? A. Obtain a court order to give the blood B. Coerce the husband into giving the blood C. Call security and have the husband removed from the hospital D. More information is needed about the wife's preference and if the husband has her medical power of attorney

D. More information is needed about the wife's preference and if the husband has her medical power of attorney

A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain

D. Psychomotor domain

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? A: "Avoid rushing when documenting an entry in the medical record" B: "Use correction fluid to remove the entry" C: "Draw a single line through the statement and initial it" D: "Enter only objective and factual information about a patient in the medical record"

D: "Enter only objective and factual information about a patient in the medical record"

Which of the following documentation entires is most accurate? A: "Patient walked up and down hallway with assistance, tolerated well" B: "Patient up, out of bed, walked down hallway and back to room, tolerated well" C: "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk" D: "Patient walked 50 feet and back down hallways with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise"

D: "Patient walked 50 feet and back down hallways with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise"

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know whats going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? A: "The patient has a defiant attitude and is demanding test results" B: "The patient appears to be upset with the nurse because he wants his test results immediately" C: "The patient is demanding and is complaining about the doctor" D: "The patient stated feelings of frustration from the lack of information received regarding test results"

D: "The patient stated feelings of frustration from the lack of information received regarding test results"

A nursing professor is teaching a nursing student about caring for patients who use herbal preparations in addition to prescribed medications. Which of the following statements made by the student indicates that the student understands herbal preparations? A: "Herbal preparations are regulated by the FDA; therefore I need to tell patients that they are completely safe." B: "They are natural products and therefore are safe as long as you use them for the conditions that are indicated." C: "These preparations are covered by insurances, including Medicare, Medicaid, and private payers." D: "We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

D: "We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

Meditation may compound the effects of which of these medications? A: Prednisone and antibiotics B: Insulin and vitamins C: Cough syrups and aspirin D: Antihypertensive and thyroid-regulating medications

D: Antihypertensive and thyroid-regulating medications

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A: A local skin infection requiring antibiotics B: Sensitive skin that requires special bed linen C: A stage III pressure ulcer needing the appropriate dressing D: Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

D: Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? A: Lupus and diabetes B: Ulcers and hepatitis C: Heart disease and pancreatitis D: Chronic back pain and arthritis

D: Chronic back pain and arthritis

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A: Necrotic tissue B: Wound drainage C: Wound circumference D: Cleansed wound

D: Cleansed wound

Complication of wound healing: Visceral organs come through the wound opening. Surgical emergency. A: Hemorrhage B: Infection C: Dehiscence D: Evisceration

D: Evisceration

Moral/ethical principle: Duty to be faithful to commitments; confidentiality and privacy. A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

D: Fidelity

Acting in accordance with an appropriate code of ethics and accepted standards of practice. It is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. A: Altruism B: Autonomy C: Human dignity D: Integrity E: Social justice

D: Integrity

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? A: Fluid status B: Potassium C: Lipids D: Nitrogen balance

D: Nitrogen balance

Drainage classification: Bright red; indicates active bleeding. A: Serous B: Purulent C: Serosanguineous D: Sanguineous

D: Sanguineous

Stage the pressure ulcer: Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. A: Stage I B: Stage II C: Stage III D: Stage IV

D: Stage III

Stage the pressure ulcer: Full-thickness tissue loss. Exposed bone, tendon, or muscle. Possible slough or eschar. Often undermining & tunneling. A: Stage I B: Stage II C: Stage III D: Stage IV E: Unstageable

D: Stage IV

On entering the room the nurse sees the patient crying softly. What is the most therapeutic response? A: Using silence B: Asking, "Why are you crying today?" C: Using therapeutic touch D: Stating, "I see that you're crying."

D: Stating, "I see that you're crying."

A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome related to using this additional modality? A: To eat less food B: To control diabetes C: To live longer without acquired immunodeficiency syndrome (AIDS) D: To learn how to control some autonomic nervous system responses

D: To learn how to control some autonomic nervous system responses

Models/theories of ethical reasoning: What is best for the most people; main emphasis is on the outcome/consequences. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

D: Utilitarianism/Consequentialism

Newborns spend more time in ___________ sleep.

Deep

Which geriatric cognitive disorder is considered a life-threatening medical emergency that requires immediate intervention?

Delirium

Alzheimer's Disease can lead to which cognitive disorder in geriatrics?

Dementia

Which cognitive disorder is the #1 cause of a loss of quality of life in older adults?

Depression

Which cognitive disorder is the most common, but most untreated disorder in older adults?

Depression

What are the 3 most common cognitive conditions in geriatrics?

Depression, delirium, depression

What is pseudoaddiction?

Development of abuse-like behaviors that are driven by desperation surrounding unrelieved pain and are eliminated by effective pain management.

Communication Forms: Verbal

Different meanings to different people Focus on: vocab, pace, clarity, timing, humor, etc.

Which group of individuals is at a very high risk for intimate partner violence?

Disabled women are at very high risk Women with unwanted/mistimed pregnancies are at a high risk

What is diabetic retinopathy?

Disease of the retina in diabetics due to high blood sugar

What is a wound?

Disruption of the integrity and function of tissues in the body

What is xerostomia?

Dry mouth due to no stimulation to salivary glands

What is central sleep apnea?

Dysfunction in the respiratory control center of the brain <10% of cases

Models/theories of ethical reasoning: Requires context of the situation; takes into account variances in culture/societal norms; what is right for one group may not be right for another. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

E: Feminist Ethics/Ethics of Care

Moral/ethical principle: Duty to treat all patients fairly, without regard to age, socioeconomic status, or other variables; allocation of scarce resources. A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

E: Justice

Acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation. A: Altruism B: Autonomy C: Human dignity D: Integrity E: Social justice

E: Social justice

Stage the pressure ulcer: Base of wound is not visible. Full-thickness tissue loss. Completely obscured by slough or eschar. Necrotic tissue present. A: Stage I B: Stage II C: Stage III D: Stage IV E: Unstageable

E: Unstageable

___________ __________ is an overlooked cause of musculoskeletal injury in the geriatric population.

Elder abuse

What does EHR stand for?

Electronic health record

-Public has a right to expect that health data and healthcare information will be centered on patient safety and improved outcomes throughout all segments of the healthcare system and the data and information will be accurately and efficiently collected, recorded, protected, stored, utilized, analyzed, and reported -Supports efforts to further refine the concept and requirements of the patient-centric EHR -All stakeholders must be integral participants in the design, development, implementation, and evaluation phases of the electronic health record -The registered nurse must be involved in the product selection, design, development, implementation, evaluation and improvement of information systems and electronic patient care devices used in patient care settings. The above are the ANA's position regarding what?

Electronic health records

What is kyphosis?

Enhanced thoracic curve (kind of over-hunched) Commonly seen in aging

Symptoms of localized infection

Erythema, edema, tenderness, warmth, drainage

How often should you ambulate a patient?

Every 2 hours

Pressure Ulcer Development: Pressure Duration

Extended pressure blocks blood flow and nutrients Problems -low pressure, prolonged period -high pressure, short period

Models/theories of ethical reasoning: Each situation creates own rules and principles; emphasizes the uniqueness of the situation and respect for person in that situation. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

F: Situational

Moral/ethical principle: Duty to tell the truth; is lying to a patient ever justified? A: Autonomy B: Beneficence C: Non-maleficence D: Fidelity E: Justice F: Veracity

F: Veracity

What pain scale is a visual scale where patients choose a facial expression that best corresponds with their pain (from smiling to a harsh grimace)?

FACES (Wong-Bakers Faces) scale

What does FLACC stand for? What does it look like?

Face Legs Activity Cry Consolability

Why are nursing handovers being investigated?

Failure to mention information may result in delays in treatment or diagnosis for the patient, inappropriate treatment, or failure to provide appropriate care; accurate handovers are critical to ensure continuity of care and patients' safety

True or False: Disorientation, loss of language skills, and poor judgement are normal signs of aging.

False

True or False: Emergency contraceptive only works if you use it within the first 24-48 hours.

False

True or False: Herpes HSV II is a curable STI because of the new antivirals, such as acyclovir.

False

True or False: Oral contraceptives are effective after two consecutive days of use.

False

True or False: The withdrawal (pull-out) method is not an effective method of birth control.

False

True or False: Through the alveolar capillary membrane, carbon dioxide transfers to the blood and oxygen transfers from the blood to the alveoli.

False Oxygen transfers to the blood and carbon dioxide transfers from the blood to alveoli

T/F: Macular degeneration is when peripheral vision starts to deteriorate and only central vision remains

False; central vision deteriorates while peripheral vision remains

True or False: Delirium is a risk factor for dementia.

False; dementia is a risk factor for delirium

T/F: Integrative nursing principle #6 focuses only on the health and wellbeing of the patient

False; it is also the caregiver

T/F: Presbyopia is abnormal loss of near focusing ability that occurs with age

False; it is normal loss

T/F: Quotes should not be included in documentation.

False; it should be when describing

T/F: Hypertensive retinopathy is a disease of the retina due to an increase in blood flow of the blood vessels

False; it's due to a decrease in blood flow

True or False: Sexuality is not lifelong and ends once individuals reach 70+.

False; sexuality is lifelong

T/F: When correcting errors for documentation, you are allowed to scribble it out.

False; should follow institutional policy

T/F: Abbreviations are not allowed when documenting.

False; they are allowed, but should comply with institutional policies

T/F: Areas that do not apply to the patient can be left blank during documentation.

False; you should never leave blanks during documentation

Example of a secondary source

Family, health care team, medical records, nurse's experience

What is the general term for pyrexia?

Fever

Signs/Symptoms of pyelonephritis

Fever Shaking chills Flank pain Urinary urgency and frequency Dysuria Burning Nocturia Hematuria Anemia and fatigue Proteinuria Leukocytes in urine

What is remittent fever?

Fever spikes and falls without a return to acceptable temperature levels

Symptoms of systemic infection

Fever, chills, fatigue, loss of appetite

For individuals that received a vasectomy, how long should they utilize another birth control method after the procedure?

First 3 months

Thorax: Define crackles

Fluid in lungs

Management of urinary calculi

Fluids, pain relief, diet change

What are the most common fall injuries?

Fractures of hip, spine, forearm, ankle, pelvis, upper arm, and hand

Which of the following models/theories of ethical reasoning matches this description: Case-based reasoning; does not focus on rules or theories, but practical decision making; may compare to previous cases; may be combined with other models/theories. A: Deontological B: Teological C: Principlism D: Utilitarianism/Consequentialism E: Feminist Ethics/Ethics of Care F: Situational G: Casuistry

G: Casuistry

_____ is when the optic nerve is damaged and eye pressure increases, causing altering vision.

Glaucoma

What is disenfranchised grief?

Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption

Where are lymph nodes the most abundant?

Head and neck

4 Main Complications of Wound Healing

Hemorrhage Infection Dehiscence Evisceration

What are the phases of wound healing?

Hemostasis Inflammatory Proliferation Maturation (Remodelling)

What is nociception?

How noxious stimuli are perceived as pain

What is the first principle of integrative nursing?

Human beings are whole systems inseparable from their environments

What is a medical diagnosis?

Identification of a disease condition based on specific evaluation of signs and symptoms

List Pressure Ulcer Risk Factors

Impaired sensory perception, impaired mobility, altered LOC, shear, friction, moisture

Pain triggered by specific movements or activities is known as?

Incident-related pain

What is Piaget's theory of cognitive development?

Individuals move from one stage to another seeking cognitive equilibrium to build mental structures and adapt to the world Stages -Infancy: sensorimotor period; progress from reflex activity to simple repetitive actions -Early childhood: preoperational period; thinking using symbols; egocentric -Preschool: use of symbols; egocentric -Middle childhood: concrete operations period; logical thinking -Adolescence: formal operations period; abstract thinking

What is Erikson's theory of psychosocial development?

Individuals need to accomplish a specific task before mastering the respective stage and progressing to the next Stages -Infancy: trust vs. mistrust -Early childhood: autonomy vs. shame and doubt (self control and independence) -Preschool: initiative vs. guilt (highly imaginative) -Middle childhood: industry vs. inferiority (engaged in activities) -Adolescence: identity vs. role confusion (includes sexual maturity) -Young adult: intimacy vs. isolation (affiliation vs. love) -Adult: generativity vs. stagnation -Older adult: integrity vs. despair

Bowel elimination differences in infants and elderly

Infants -more rapid peristalsis -lack of neuromuscular development Elderly -lose muscle tone in pelvic floor and anal sphincter

What is the fourth principle of integrative nursing?

Integrative nursing is person-centered and relationship-based

What is the leading cause of injury to women in the United States?

Intimate partner abuse

When testing for balance, why is it important to have the patient walk in a straight line in a heel-to-toe fashion?

It decreases the base of support and accentuates any problem with coordination

Examples of treatments for urinary incontinence

Kegel exercises, meds, vaginal cones, bladder training, prompted voiding, catheters, incontinence undergarments

Types of UTIs: WHat is pyelonephritis?

Kidney infection

What is the general term for urinary calculi?

Kidney stones

What is the difference between law and ethics?

LAW -rules to guide and protect society -enforced -may develop from moral/ethical principles ETHICS -declaration of right and wrong actions -no uniform system of enforcement

What is a pressure ulcer?

Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear or friction

What is the biggest fear of geriatric individuals?

Loss of independence

The most common back injury is to the __________ muscle group.

Lumbar

What is the preparation stage of behavioral change?

Making small changes in preparation for change Implication: pt believes advantages outweighs disadvantages; may need help with planning Example: signing up for a gym membership

What is the most common unintentional tort action that is brought against nurses?

Malpractice

Types of relationship boundaries

Material, social, personal, professional

What are the elements of therapeutic communication?

Message, sender, channel, receiver, feedback

Where is the point of maximal impulse (PMI) located?

Mitral valve

Communication Forms: Nonverbal

More revealing and truthful than verbal Focus on: facial expressions, body language, gait, sounds (sighs), etc.

What is obstructive sleep apnea?

Muscles/structures relax during sleep so airway is obstructed Increased risk for HTN, MI, stroke

75-80% of sleep time is spent in which stage?

NREM

What is nonblanchable erythema?

No blanching with pressure, possible tissue damage

What drug is often used first for pain?

Non-opioid analgesic

What is the precontemplation stage of behavioral change?

Not intending to make changes within the next 6 months Implication: pt is not interested in info about behavior and may be defensive

What is the most used pain scale?

Numeric Pain Intensity Scale (0-10)

Chemoreceptors in the aorta and carotid are sensitive to __________.

O2

Respiration is the exchange of ______ and ______ during cellular metabolism.

O2 and CO2

General survey is an _____________ way to assess a patient.

Objective

What are the 2 types of sleep apnea?

Obstructive and central

What is heat exhaustion?

Occurs when profuse diaphoresis results in excess water and electrolyte loss caused by environmental heat exposure

When are face masks or eye masks used?

Only when splashing is likely

When percussing, if the sound is "drum-like", where are you most likely percussing?

Over air or empty space

When percussing, if the sound is "dull", where are you most likely percussing?

Over organs

ABCSP: Define P

Pain -moaning/groaning, patient statements, grimacing

What does PACSLAC stand for?

Pain Assessment Checklist for Seniors with Limited Ability to Communicate

What is nociceptive pain?

Pain caused by tissue injury in the joints, bones, muscles and various internal organs. In contrast to neuropathic pain, the patient's nervous system is functioning normally, transmitting information about the injury to the brain.

What is neuropathic pain?

Pain initiated or caused by a primary lesion or dysfunction in the nervous A painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process system

What is breakthrough pain?

Pain that increases above the level of pain addressed by the ongoing analgesics; this would include incident pain and end-of-dose failure.

What is neuropathic pain?

Pain that is initiated/caused by a primary lesion or dysfunction in the nervous system. It is characterized by hyper-excitability of the nociceptors

Example of a primary source

Patient

Mobility: Respiratory Changes

Patient is at risk for: -atelectasis: collapse of alveoli (leads to partial collapse of lung) -hypostatic pneumonia: inflammation of lung tissue from stasis Both decrease oxygenation, prolong recovery, and adds to discomfort

Crackles are commonly heard in which patients?

Patients with pneumonia

What is relapsing fever?

Periods of febrile episodes and periods with acceptable temperature values (longer than 24 hours)

What is chronic pyelonephritis?

Persistent or recurring episodes of acute pyelonephritis (often related to E. coli)

What is PPE?

Personal protective equipment

-Non-opioid analgesics (acetaminophen, NDSAIDs) -Opioid analgesics -Anti-depressants (for neuropathic pain) -Anti-convulsants (for neuropathic pain) -Steroids (adjuvant use for neuropathic pain or CNS conditions) -Bisphosphonates (adjuvant use for bone pain) -Local anesthetics (or acute localized pain, some neuropathic pain) -Benzodiazepines -The above are examples of...

Pharmacologic pain interventions

What are the stages of behavioral change?

Precontemplation Contemplation Preparation Action Maintenance

3 Development Factors of Pressure Ulcers

Pressure intensity, pressure duration, tissue tolerance

What is prima facie and how does it relate to ethics?

Prima facie: 1st impression Refers to something being accepted as correct until or unless it is shown to be otherwise

What are the levels of prevention?

Primordial Primary Secondary Tertiary

What is lordosis?

Pronounced lumbar curve (aka swayback) Commonly seen in obesity

PQRSTU: Define P

Provocative/Palliative; what makes the pain better or worse

Which type of drainage is yellow and has a strong odor?

Purulent

Strategies to increase mobility

Quadriceps and Gluteal Drills -Quads: Ask the patient to push down with knees and flex feet -Gluteal muscles: ask the patient to pinch buttocks together Arm Exercises -Biceps: install a trapeze bar, or encourage lifting of objects like water bottle -Triceps: ask patient to lift upper body off the mattress by pressing with palms Dangling -a seated position at the side of the bed -Helps avoid orthostatic hypotension when first getting up -Allows patient to experience being upright with limited risk of falling Activities of Daily Living (ADLs) -includes: brushing of teeth dressing, bathing, feeding self -encourage patient to get up to the chair before attempting to walk -performing ADLs exercises many of the muscle groups used in ambulation

What is QSEN?

Quality and Safety Education for Nurses Developed to help prepare future nurses to improve quality of healthcare and ensure safety

PQRSTU: Define Q

Quality or Quantity; how the pain feels like

Abdominal Ausculation/Palpation Sequence

RLQ, RUQ, LUQ, LLQ

PQRSTU: Define R

Radiation; is the pain localized or does it move

pH can play a role in the _______ and _________ of respirations.

Rate and depth

What is the spleen responsible for?

Recycling RBCs (gets rid of old ones and stores new ones) Also filters microorganisms from the blood

What is blanchable hyperemia?

Redness of skin caused by capillary dilation Blanching occurs when pressure is applied

How does moisture affect the skin?

Reduces skin resistance and softens skin Largely affects immobilized patients

What is neurogenic bladder?

Reflex incontinence or urinary retention due to spinal cord injury

What are tonsils responsible for?

Respond to local inflammation in response to respiratory and GI tract

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." B 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." A 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" R 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." S

S 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." B 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." A 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." R 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?"

Which heart sound is referred to as a ventricular gallop?

S3 This sound can normally be heard in children and athletes but is not normal in older adults

Which heart sound is referred to as an atrial gallop?

S4 Hearing this sound is never normal

Components of SBAR

S: Situation -what is going on, reason for communication -5-15 seconds B: Background -brief history, current status A: Assessment -what you think problem is -vitals can go here or in situation R: Recommendation -what is needed and when

What does SBAR stand for?

S: Situation B: Background A: Assessment R: Recommendation

ABCSP: Define S

Safety -seated properly, side rails, environmental dangers

Which type of drainage indicates active bleeding?

Sanguineous

Relationship Boundaries: Concerns

Self-disclosure, gift-giving, social media

If the senses are not used for a long period of time, they will lose sense. This is known as?

Sensory deprivation

PQRSTU: Define S

Severity; intensity of pain (scale of 0-10)

What is sloughing?

Shedding of tissue cells

What is the best position to measure blood pressure?

Sitting

What is the difference between sleep and rest?

Sleep -cyclical states/altered consciousness -decreased motor activity/perception -selective response to stimuli Rest -mild to no activity -relaxation; stress-free -results in feeling refreshed

What is shearing?

Sliding of skin and tissue while underlying structures are stationary EX: Patient sliding down when HOB is raised

What are the stages of the sleep cycle?

Stage 1: NREM -lighest level -easy to wake Stage 2: NREM -period of sound sleep -relaxation progresses Stage 3: NREM -initial stages of deep sleep Stage 4: NREM -deepest stage of sleep -most difficult to awaken -sleep walking can occur Stage 5: REM -rapid eye movement -hard to arouse -dreaming in full color

Isolation Precautions: Tier One

Standard Precaution -applies to blood, body fluids, secretions/excretions, non-intact skin, mucous membranes) -hand hygiene -nail care -barrier precautions (gloves, gowns, masks, etc.) APPLIES TO ALL PATIENTS BECAUSE POTENTIAL FOR TRANSMISSION IS ALWAYS PRESENT

Treatment of C. diff

Stool transplant, oral metronidazole, vancomycin, or fidaxomicin (used for recurrent c. diff)

What is Lasegue's test?

Straight leg raise (dorsiflexed) for sciatic nerve pain

Types of Urinary Incontinence

Stress, urge, overflow, function, reflex, mixed

Which lung sounds indicate an emergency?

Stridor

Health history is a ____________ way to assess a patient.

Subjective

What is the MOST reliable indicator of pain?

Subjective report from the patient

What is the maintenance stage of behavioral change?

Sustained change over time; begins 6 months after action has started and continues indefinitely Implication: changes need to be integrated into the pt's lifestyle

Vitals: Blood Pressure

Systolic: <120 mmHg Diastolic: <80 mmHg

What developmental stages used to be used to assess sexual development?

Tanner stages

The ​_________ __________ __________​ is a closed-loop communication technique used to evaluate patient understanding and retention of material.

Teach Back Method

What is a heat stroke (value and signs)?

Temperature of 104°F or more Signs/Symptoms: -confusion -increased thirst -nausea -muscle cramps -visual disturbances

Pulse Locations (that we use)

Temporal (children) Carotid Apical Brachial Radial Posterior tibialis Dorsalis pedis

What is tolerance?

The body's normal response to continued exposure to a medication, resulting in a reduction of one or more of the drug's effects over time.

What is physical dependence?

The body's normal response to the continued use of several classes of medications.

How does the Braden scale work?

The higher the number, the lower the risk for skin impairment

What is passive range of motion?

The movement performed by examiner

What is active range of motion?

The movement performed by the patient

What does the Visual Analogue Scale look like? What kind of scale is it?

Thermometer scale

PQRSTU: Define T

Timing; how long has the pain been present

Pressure Ulcer Development: Pressure Intensity

Tissue ischemia and death can occur if pressure is higher than normal capillary pressure -includes blanchable hyperemia and nonblanchable erythema

What is the primary function of a dressing?

To absorb drainage

What is the mission of Community Cancer Connections?

To facilitate long-term wellbeing in those affected by cancer by linking to information, providers, resources and services

Why is the spine in an alternating concave-convex shape?

To help absorb shock

What was the purpose of the article, "Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalized patients"?

To identify which nursing handover style(s) are associated with improved outcomes for patients in the hospital setting and which nursing handover style(s) are associated with improved nursing process outcomes.

What is the purpose of a therapeutic relationship?

To improve the patient's health status

what is a gait belt used for?

To safely transfer a patient Always walk on the weaker side of the patient when ambulating

What is caring touch?

Touching when there is no physical need -provides comfort and encouragement, but some patients may interpret it differently or some cultures may not accept it

Thorax: Define wheezing

Trouble with air exchange

Thorax: Define ronchi

Trouble with clearing of lungs

T/F: Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense

True

T/F: Principle #3 of integrative nursing is that nature has healing and restorative properties that contribute to health and wellbeing

True

T/F: Refractory pain is pain that is resistant to ordinary treatment

True

T/F: Stereognosis is the mental perception of depth or three-dimensionality by the senses, usually in reference to the ability to perceive the form of solid objects by touch.

True

T/F: There is increasing evidence of CAM benefit, but the science to support the effectiveness is early in its development

True

True or False: 80% of adolescents are sexually active by late teens to early 20's.

True

True or False: As pressure in the lung increases, the diameter also increases.

True

True or False: Both males and females can get breast cancer.

True

True or False: Cervical caps and sponges are less effective as birth control methods for women who have given birth.

True

True or False: Chlamydia is the most common bacterial STI in the US.

True

True or False: Chlamydia, Gonorrhea, and Syphilis are curable STI's.

True

True or False: Grief work is never completely finished.

True

True or False: If you miss more than one day of an oral contraceptive, you must use a back-up method for seven days.

True

True or False: It is normal to have a little bit of residual volume after exhaling.

True

True or False: Liability must be present for a malpractice case to move forward.

True

True or False: Mourning is strongly influenced by culture.

True

True or False: One in four adult Americans have genital herpes HSV II.

True

True or False: The family is the best source of information for culturally sensitive assessments.

True

True or False: The national recommendation is that all sexually active adults 25 and younger get screened for Chlamydia yearly.

True

True or False: Visual alignment is normally impaired in children.

True

True or False: You can buy emergency contraceptives over the counter without a prescription regardless of age.

True

True or False: The Centers for Medicare and Medicaid Services no longer reimburses hospitals for the additional costs of caring for patients who develop CAUTI during hospitalization.

True (since 2008!) Found in the "Estimating hospital costs of catheter-associated urinary tract infection" article

What is friction?

Two surfaces moving across each other that affects the epidermis -Occurs in those who are restless or have uncontrollable movements or during transfers EX: Being pulled on linens instead of lifted

What about the touch sense decreases with age?

Two-point discrimination and vibratory sense

PQRSTU: Define U

Understanding; how has this pain affected you (EX: no longer able to walk, can't talk, etc.)

Diversity matters because health outcomes are __________.

Unequal

How much of communication is nonverbal?

Up to 90%

Types of UTIs: What is urethritis?

Urethra infection

Causes of urinary calculi

Urinary stasis, increased solute concentration

What is therapeutic communication?

Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship

What age groups are most at risk for wounds?

Very young and very old

When do you empty a urostomy bag?

When it is about 1/3 full

Integrative nursing focuses on ___.

Whole person, whole system

Name the three important dimensions to consistently measure to determine wound healing.

Width, length, depth

What are diabetic wounds?

Wounds that are usually on the foot

Wellbeing is often defined as...

a balance of body and mind, a state of health and wellness, which is not solely the absence of physical ailments

The best way to determine type of pain, what is causing the pain, and how the pain will be effectively treated is through....

a good pain assessment using PQRSTU

What are the Tanner stages?

a system used to measured the development of secondary sex characteristics during puberty for both males and females

What is graphesthesia?

ability to recognize writing on the skin purely by the sensation of touch

What is scoliosis?

abnormal lateral curvature of the spine

What is asepsis?

absence of pathogenic microorganisms

What is advocacy?

act of supporting or recommending something/someone

What is social justice?

acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation

What is hypoventilation?

alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient CO2

What is residual volume?

amount of air left in the alveoli after a full expiration

What is tidal volume?

amount of air that we can exhale

What are the 2 most important moral/ethical principles?

autonomy and non-maleficence

What is acute pyelonephritis?

bacterial infection of the kidney (spread from bladder to ureters to kidneys)

What is principalism?

based on principles of autonomy, beneficence, non-maleficence, and justice

What is definition of malpractice?

behavior of a professional person's wrongful conduct, improper discharge of professional duties, or failure to meet the standards of care which result in harm to another person

What is proprioception?

being aware of where your body is in space

What is ethical relativism?

belief that it is acceptable for ethics and morality to differ among people or society TWO TYPES: ethical subjectivism and cultural relativism

What is ethical objectivism?

belief that universal or objective moral principles exist

What are foot drops?

caused by weakness or paralysis of the muscles involved in lifting the front part of the foot

A nurse plans to provide education to the parents of school-age children, which includes the increased prevalence of __________________ as a result of children being less physically active outside of school.

childhood obesity

What is a nursing diagnosis?

clinical judgement about the patient in response to an actual or potential health problem

What is altruism?

concern for the welfare and well-being of others

Iatrogenic disease/condition

condition caused by medical treatment

What is moral courage?

courage to take action and challenge unacceptable practices and policies

How is the chest wall affected by neuromuscular disease?

decreased ability to expand or contract chest wall

How hypovolemia affect oxygenation?

decreased circulating blood volume results in hypoxia to blood tissues

How is the chest wall affected by CNS alterations?

disease or trauma that affects the medulla oblongata or spinal cord

Integrative nursing is part of the shift from a ______ model in healthcare to promoting preventive care and wellbeing.

disease-centered

What is beneficence?

duty to actively do good for patients

What is veracity?

duty to tell the truth

What is Kantian deontology?

each rational being is ethically bound to act only from a sense of duty; when deciding how to act, the consequences of one's actions are considered to be irrelevant Kant believes that people can only be moral if they perform dutiful actions.

Fill in the Blank.​ While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider's offices over the past 6 months. This type of feature is most common in a(n) ____.

electronic health record (EHR)​.

What is contract law?

enforcement of agreements among private parties that include an obligation or duty EX: employment contract

What is diffusion?

exchange of respiratory gases in the alveoli and capillaries of tissues

Understanding of words is good, but finding the words to speak is difficult. This is known as...

expressive aphasia (motor/Broca's)

Documentation should be ___ and ___, not judgmental.

factual; objective

What is negligence?

failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance

What is intermittent fever?

fever spikes interspersed with usual temperature levels (returns to acceptable value at least once in 24 hours)

What are rhonchi caused by?

fluid or mucus buildup Have patient cough to try to clear it up

Walking through/immersing oneself in a forest to allow senses to absorb the surroundings is known as...

forest bathing; studies have shown benefits to cardiovascular and metabolic function

Examples of assistive devices

gait belt, walker, cane, crutches, wheelchairs, hoyer lift

When both motor and sensory mechanisms are impaired, it is known as...

global aphasia

Principle #2 of integrative nursing: human beings have the innate capacity for ____.

health and wellbeing

What is eudaimonia?

high level of happiness or well-being

What is integrity?

holding on to principles like honesty and loyalty

What is hypoxia?

inadequare tissue oxygenaton at a cellular level S/S: confusion, restlessness, increased HR, increased RR, anxiety, dyspnea

How does increased metabolic rate affect oxygenation?

increased oxygen demand

How is the chest wall affected with pregnancy?

inspiratory capacity declines from pushing up on the diaphragm and results in dyspnea with exertion and increased fatigue

Types of Urinary Incontinence: Mixed

involuntary leakage associated with stress and urgency

Patient factors affecting communication

language barriers, cognitive skills, sensory perceptual alterations (hearing, vision, etc.), physiological barriers (breathing, oral, etc.)

What are LARC's?

long acting reversible contraception

For acute pain, patients should be prescribed with the ___ effective dose of immediate-release opioids in quantities no greater than the anticipated duration of pain severe enough to require opioid treatment.

lowest

How does inhalation of toxic substances affect oxygenation?

makes hemoglobin unavailable for transport EX: carbon monoxide strongly binds with CO2 and causes functional anemia

What is the thymus responsible for?

maturation of T cells

What is forced vital capacity?

max amount of air that can be removed during forced expiration

What is ventilation?

moving gases into and out of lungs

What is eschar?

necrotic tissue

Pressure Ulcer: Stage 1

nonblanchable erythema of intact skin Primary goal: prevent skin breakage

Notes during documentation should be ___.

objective

What is the definition of liability?

obligation that has been incurred or might incur through any act or failure to act

What is moral distress?

occurs when one knows the ethically correct action to take but feels powerless to take that action

What are contractures?

permanent contraction of a muscle

What is a whistleblower?

person who identifies an incompetent, unethical, or illegal situation or action of others, in the workplace and reports it to someone who may have the power to stop the wrong

What are particular moral principles?

principles that are particular to a a certain group EX: cultural norms/family norms, religious codes, professional codes, organizations

What are "standards of professional practice"?

professional behavior as a nurse

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to ______________________________.

promote venous return to the heart

What is perfusion?

pumping oxygenated blood to the tissues and returning deoxygenated blood to the lungs

When speech is effortless, but meaning is impaired. This is known as...

receptive aphasia (sensory/Wernicke's)

What is human dignity?

respect for the inherent worth and uniqueness of individuals and populations

What is autonomy?

right to self-determination

What is constitutional law?

rights, privileges, and responsibilities that are stated or inferred from the US constitution and bill of rights EX: Right to privacy act

What is moral integrity?

sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one's actions and perceptions

Stimulation of ____ aid in the transmission of impulses to the brain.

sensory nerve fibers

What are the categories of the braden scale?

sensory perception, moisture, activity, mobility, nutrition, friction and shear

Types of Drainage

serous, purulent, serosanguineous, sanguineous

Symptoms of urinary calculi

sharp, severe, sudden pain "Worst pain I've ever had"

What is health literacy?

the ability to read, understand and act on health information - is an emerging public health issue that affects all age, race and income levels

What is basal metabolic rate (BMR)?

the amount of energy expended while at rest

Pharmacologic tolerance is...

the build up of tolerance. The individual may need a higher dosage for the same effect as the initial dosage; this can be good or bad.

What is neglect?

the failure to provide needed care that results in physical, mental, or emotional harm to a person ALSO INCLUDES SELF-NEGLECT

What is exploitation?

the illegal or improper use of a vulnerable adult's resources for another's profit or advantage

What is the Romberg Test?

the patient should be standing feet together and eyes closed, with minimal swaying for about 20 seconds

Sensory deficit causes...

the senses to deteriorate

What is bereavement?

the state of being without, or the absence of someone or something valued

The ANA's position statement [on Inclusion of Recognized Terminologies Supporting Nursing Practice within Electronic Health Records and Other Health Information Technology Solutions] supports ___.

the use of recognized terminologies supporting nursing practice as valuable representations of nursing practice and to promote the integration of those terminologies into information technology solutions

What is the purpose of hemoglobin?

transport oxygen to tissues

What is metaethics?

understanding the language of morality through an analysis of the meaning of ethically related concepts and theories

What is hyperventilation?

ventilation in excess of that required to eliminate CO2 from cellular metabolism

What is "scope of practice"?

what someone in a profession is legally allowed to do

What is primary intention?

wounds that heal under conditions of minimal tissue loss Usually from surgical incisions or sutures

What is secondary intention?

wounds that require a a lot of tissue replacement (open wound)