Test 4 Review Questions

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask?

"Do you work around loud noises at work?" Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend?

"Get the human papillomavirus vaccine." Human papillomavirus (HPV) is a DNA virus also called genital warts and is a sexually transmitted infection (STI). A vaccine is now available to prevent this disease. Male partners with HPV may or may not have lesions. Women should avoid douching to prevent STIs, as they remove normal protective bacteria in the vagina and increases the risk of getting some STIs. The Norplant system is a contracteptive method and does not prevent STIs.

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body." The client needs further instruction when she says she can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician.

A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply.

"I feel like I'm so ugly.", "What good am I?", "I'm such a horrible person.", "Who would want to marry me now the way I look?" People who do not possess a healthy self-concept are less able to cope with life, often expressing feelings of inferiority, self-doubt, and self-dislike. Statements that relate negative feelings (such as being ugly, questioning one's ability, being a horrible person, questioning attractiveness) suggest a dysfunction. Liking one's self and one's life expresses positive feelings that would be associated with a positive self-concept.

A client is requesting that the nurse speak with the physician regarding alternate treatment options. What comment by the nurse would be most appropriate to help the client identify and use her personal strength?

"I wonder why you want me to talk with the doctor? If you talk with them, you could hear all the treatment options firsthand. I will gladly stay with you while you talk to the doctor." Nurses frequently fall into the trap of "doing" for clients. Some clients have even learned to communicate a manipulative helplessness that encourages the nurse to take charge. "I wonder why you want me to talk with your doctor?" expresses a question to get the client to think about an opportunity to use her personal strength. Following that query with a positive that could occur (the client can hear all the treatment options firsthand) strengthens the option. Finally, offering to be present affirms that the nurse remains an advocate while "helping" the client speak for herself.

While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?

"Sometimes it seems like I can never get a moment to myself." Caregiver role strain may be exhibited by statements of exhaustion, frustration, or seeming overwhelmed. If the client states that time to themselves is rare, he or she may be feeling consumed with care for the client with chronic pain. Feeling badly regarding a loved one's pain, discussing insurance coverage, and helping the loved one by doing household tasks do not indicate caregiver role strain.

The family of an intensive care unit (ICU) client, who cannot be roused and does not respond to stimuli, asks the nurse how they should communicate with the client. Which of the following should the nurse recommend?

"Speak to the client as they are likely to hear what is being said, even if there is no response." A client who cannot be roused and does not respond to stimuli is in a coma or unconscious state. Guidelines for communicating with clients who are unconscious are: the person is often likely to hear what is being said, even if there does not appear to be a response; hearing is believed to be the last sense lost; assume the person can hear you and talk in a normal tone of voice; and keep environmental noises (radio) as low as possible so the person can focus on the communication.

The nurse assessing an adolescent's need for further information should ask which of the following questions?

"What questions or concerns do you have about your sexual health?" An open-ended, nonthreatening question related to the patient's need for further information should be included while obtaining a sexual history

A nurse is visiting the home of a first-time mother and her newborn. The nurse is teaching the mother about the newborn's sleep needs. The nurse would inform the mother that newborns sleep approximately how many hours per day?

14 to 20 hours Explanation: On average, infants require 14 to 20 hours of sleep each day.

What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg?

24.8 A BMI of 24.8 is correct. The BMI is the ratio of height to weight that more accurately reflects total body fat stores in the general population. It is equal to: weight in kg/height in m^2.

Which example best supports the diagnosis of Sexual Dysfunction: Dyspareunia?

A 50-year-old woman in the process of menopause has pain and burning during intercourse. Dyspareunia refers to pain and burning during intercourse. This is a common cause of sexual dysfunction, especially during menopause. A colostomy, fear of blood pressure elevation, and lack of interest in sex may lead to the nursing diagnosis of Sexual Dysfunction, but not related to dyspareunia.

Which client is most likely susceptible to the effects of disturbed sensory perception?

A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit.

The nursing diagnosis Risk for Sensory Deprivation is best suited for which client?

A client whose room at the end of the hallway has the door closed most of the time If a person experiences less than the usual stimulation, that person is below his optimum state of arousal and may be at risk for sensory deprivation.

A client states that he is pain and requests the ordered pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication. Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's physician needs to be notified at this time.

At what period of life do nutrient needs stabilize?

Adulthood Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.

The nurse is justified in assessing for sexual dysfunction among male clients who are receiving which of the following?

Antihypertensive medication Antihypertensives are among the drugs implicated in sexual dysfunction. Antibiotics, bronchodilators, and NSAIDs do not typically have this effect.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.

A nurse is caring for a 55-year-old male on an orthopedic unit. When the nurse hands the client his morning medication, he grabs her breast and squeezes it. How should the nurse best respond to this situation?

Assertively tell the client that this behavior is not acceptable Squeezing the nurse's breast can be viewed as a type of sexual harassment by the client. An assertive response by the nurse is recommended as it supports the nurse in maintaining his or her self-respect and encourages the client to accept responsibility for his behavior. Inappropriate sexual behavior by a client may cause the nurse to inappropriately respond with either passive avoidance (switching assignments) or aggressive retaliation (withholding pain medication). Legal advice would only be an option if all efforts to stop the behavior were unsuccessful.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? (Select all that apply.)

Assess for pain control 30 minutes after administering an analgesic., Consider cultural implications of the perception of pain., Provide pain medication before activity that may increase pain. Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain, and assess for pain control after medication is given. Assumptions should not be made about pain.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem. Assessment is the first step in the nursing process. Consequently, the nurse should determine the factors contributing to the client's problem before performing interventions.

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites. With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.

A nurse is providing care to a client who has undergone skin grafting to her face due to a burn injury. The client states, "I know it could have been worse, but my face will never be the same as it was. I haven't been able to look at myself in the mirror because of what I might see." The nurse interprets this statement as most likely reflecting which pattern?

Body image Although self-esteem, role performance, and personal identity are components of self-concept, the client's statements reflect her feelings about her physical appearance, or body image.

The client reports unpleasant sensation in the legs with an urge to move his legs. The nurse assesses for the following:

Client use of tobacco products, Ingestion of an antihistamine, If massaging the legs provides relief Unpleasant sensations in the legs with an urge to move the legs are symptoms of restless leg syndrome. Ingestion of antihistamines may exacerbate the symptoms. Avoiding use of tobacco and massaging of legs may bring relief. The sensation is present in the legs, not the arms. Symptoms are worse during the evening and night.

A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting?

Coma Unconscious states include asleep, stupor, and coma. Coma is characterized by an inability to be aroused and no response to stimuli. A client in a stupor can be aroused by extreme and/or repeated stimuli.

A nurse is caring for a client who has been ordered a clear liquid diet. Which of the following can be included in the client's diet?

Cranberry juice Composed only of clear fluids or foods that become fluid at body temperature and includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements. A clear liquid diet requires minimal digestion and leaves minimal residue. Low-fat milk, fruit juices or soup, and juices with fruit pulp (orange and grapefruit) are considered full-liquid diet.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

Cutaneous stimulation Cutaneous stimulation techniques include acupressure, massage, application of heat and cold, and transcutaneous electrical nerve stimulation (TENS). Reference:

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

Delusions Delusions, beliefs not based in reality, reflect an unconscious need or fear.

A client who is 5 foot 2 inches tall and weighs 120 pounds states, "I wish for once I had a normal weight and I weren't so fat." What is the priority nursing diagnosis?

Disturbed body image Disturbed body image is defined as the state in which one experiences confusion in the mental picture of one's physical self. The client is not overweight but is unable to see that due to the disturbance in body image. There is no indication of alterations in role performance or self-esteem. Disturbed personal identity is not related, as this is an inability to distinguish between self and non-self.

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (Select all that apply.)

Encourage deep breathing., Play the client's favorite music., Promote a restful environment. Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase.

The nurse is caring for a client in strict isolation and assesses that the client is apathetic and has a decreased attention span. Which nursing action should the nurse implement?

Encourage the client to share concerns and perceptions. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. A client in isolation would be in an environment with decreased stimuli and may exhibit cognitive disturbances (such as a decreased attention span) and emotional disturbances (such as apathy). The nurse needs to encourage clients to share fears, concerns, and perceptions and reassure the client that misconceptions do occur with sensory deprivation. Nursing interventions focus on maintaining a sufficient level of arousal by increasing sensory stimuli. Providing earplugs and limiting television use and touch would decrease stimulation.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. The client would benefit from the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. The phantom pain is real pain and should be treated as such. The nurse would not increase and decrease the serum level of the analgesic as needed. The nurse would not doubt the client's report of pain and would not withhold analgesia if she doubted the likelihood of the pain occurring.

A woman consumes pasta, grains, and other carbohydrates for which purpose?

Energy The main function of carbohydrates is to provide energy.

Biologic makeup comprises many characteristics that affect self-concept. Which is not part of one's biology?

Environment Sex, height, weight, and appearance are all biological characteristics that affect self-concept.

A man 50 years of age has a long history of diabetes, which is poorly controlled. What does diabetes greatly increase the man's risk of experiencing?

Erectile dysfunction Diabetes is a significant risk factor for erectile dysfunction. Retarded or premature ejaculation is less likely, since these problems do not have a vascular etiology. Diabetes does not create an appreciably increased risk of developing STIs, though persons with diabetes do have an increased susceptibility to infections of all kinds.

What is associated with the resolution phase of the male sexual response cycle?

Feelings of relaxation and fulfillment

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation. A primary nursing concern is to prevent symptoms of sensory overload for clients. Risk for sensory overload greatly increases when unfamiliar procedures are taking place. Overstimulation can be prevented by preparing clients before procedures, using a technique called sensation (sensory) information. The purpose of this intervention is to alleviate a client's distress responses to threatening stimuli and to improve the client's coping through stimulation of the cognitive processes.

Which of the following questions would the nurse include on a self-concept assessment related to body image?

How do you feel about any physical changes you noticed recently? Body image is the person's subjective view of one's physical appearance. Therefore, asking a patient how he or she feels about physical changes addresses body image. "Do you like who you are?" assesses a person's self-esteem. Asking "Who influenced you the most growing up?" and "Who would you most like to be?" assesses a person's self-expectation.

The nurse likes to use humor to help clients deal with pain. What guidelines should the nurse follow when using humor to foster pain relief?

Humor should take into account the client's personality and circumstances. Humor should be used only with clients who are responsive to it and wish to use it. Consequently, the nurse must assess the client's personality and circumstances carefully. It should not normally be used in the presence of moderate or severe pain, though it can be used, if appropriate, when caring for older clients or those from other cultures.

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

Impaired memory Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. The nurse would include the education point that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. It is normal for infants to have eye movements, groaning, or grimacing during sleep periods. School-age children become aware of the concept of death, not preschool children. Waking from nightmares or night terrors is common during the preschooler stage.

You are the nurse caring for a client with an enlarged thyroid gland. You anticipate which nutritional deficiency is linked to the client's condition?

Iodine A chronic deficiency of iodine can lead to goiter, which manifests as an enlargement of the thyroid gland.

The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include?

LGBT youth are 2 to 3 times more likely to attempt suicide. Healthy People 2020 found that LGBT youth are 2 to 3 times more likely to attempt suicide. Lesbians and bisexual females are more likely to be overweight or obese. LGBT populations have higher rates of tobacco, alcohol, and other drug use than other populations. Lesbians are more likely to get preventive services for cancer.

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Massage, Cold, Heat The gate theory supports that the signals at the gate in the spinal cord determine which impulses eventually reach the brain. A limited amount of sensory information can be processed by the nervous system at any given moment. When there is too much information sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The theory appears to explain why mechanical and electrical interventions such as heat, cold, pressure, and massage provide effective pain relief.

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

Minimize background noises and ensure that lighting is adequate to see the nurse's face. When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration. Although most sedative-hypnotic drugs provide several nights of excellent sleep, the medication often loses its effects after 1 or 2 weeks. Alcohol and diphenhydramine should not be administered with a sedative-hypnotic drug. Increased activity assists the client in sleeping. Foods such as protein and carbohydrates have been shown to help a client sleep.

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone Naloxone is an opioid antagonist that reverses the respiratory-depressant effect of an opioid.

When a nurse asks a patient to describe her personal characteristics and traits, the nurse is most likely assessing the patient for what self-concept factors?

Personal identity Personal identity describes a person's conscious sense of who he or she is. Asking the patient to describe her personal characteristics and traits assesses a person's personal identity. Body image is the person's subjective view of one's physical appearance. Role performance is one's ability to successfully live up to societal as well one's own expectations regarding role-specific behaviors. Self-esteem can be described as the need to feel good about oneself and to believe that others hold one in high regard.

A male client informs the urology nurse that he is embarrassed because his wife rarely has time to reach sexual satisfaction, since he experiences an orgasm as soon as he enters the vagina. What is this condition best known as?

Premature ejaculation Premature ejaculation is a condition in which a man consistently reaches ejaculation or orgasm before or soon after entering the vagina. Erectile failure, also known as impotence, is the inability of a man to attain or maintain an erection to the extent that he cannot have satisfactory intercourse. Retarded ejaculation refers to a man's inability to ejaculate into the vagina, or delayed intravaginal ejaculation.

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?

Psychological reasons for overeating should be explored, such as eating as a release for boredom. The nurse would need to take into consideration that psychological reasons for overeating should be explored. One pound of body fat is equal to approximately 3,500 calories. To lose 1 pound/week, the daily intake should be decreased by 500 calories per day. Obesity can be difficult to treat due to various factors.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.

The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond?

Rephrase the direction in different terms. Rephrasing an instruction in simple terms may enhance a confused client's understanding. This is preferable to proceeding in spite of the client. Asking for help from a colleague and asking the client if she feels confused are not likely to enhance communication with the client.

Three days after surgery, a patient continues to have moderate to severe incisional pain. Based on the gate control theory, what action should the nurse take?

Reposition the patient and gently massage the patient's back. The nurse would reposition the client and gently massage the client's back using the gate control theory of pain. The gate control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relation between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Decreasing the dosage of the pain medication, but giving the doses more frequently does not follow this theory. Decreasing external stimuli in the room during painful episodes would not address the gate control theory. Advise the client to sleep following administration of pain medication does not address the gate control theory.

A young woman has just started a nursing program. She is trying to balance going to school full-time, a part-time job, and spending time with her family. Recently she has been feeling a lot of stress and doesn't feel as if she is able to do any of the three very well. Which role problem is this young woman experiencing from this role transition?

Role strain Role strain occurs when the person perceives himself as inadequate or unsuited for a role and can occur when a person is forced to assume many roles. Role ambiguity occurs when a person lacks knowledge of role expectations. This lack of knowledge causes anxiety and confusion. Role conflict is related to expectations concerning the role.

A nurse is assessing a client's self-perception. Which dimension is reflected by the client's statement, "I want to use my skills to become the best artist I can be"?

Self-expectation Self-expectation involves the "ideal" self — the self a person wants to be. It is the setting of present and future goals. Self-knowledge or self-awareness involves a basic understanding of oneself, a cognitive perception. It is consciousness of one's abilities: cognitive, affective, and physical. Self-knowledge involves basic facts (age, weight, sex) and qualities (sincere, athletic, intelligent) related to oneself. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. "Have I met my expectations? Do I like who I see in the mirror? Do I like how I behave?"

A child lists his favorite sports figures and tells the nurse he is going to be just like them. How does the nurse identify this human need?

Self-expectations Expectations for the self arise from various sources. The ideal self refers to who a person wants to be. These self-expectations develop unconsciously early in childhood and are based on images of role models such as parents, other caregiving figures, and public figures (such as a child wanting to be like a favorite sports figure). A person's self-knowledge includes basic facts (such as sex, age, race, occupation, cultural background, sexual orientation); a person's position within social groups; and qualities or traits that describe typical behaviors, feelings, moods, and other characteristics (e.g., generous, hot-headed, ambitious, intelligent, sexy). Self-evaluation refers to how well a person likes themselves. Self-actualization refers to the need to reach one's potential through full development of one's unique capabilities.

The nurse is assessing a neglected child brought to the emergency department. The grandmother of the child reports that the child remains in the crib constantly, and is only removed from the crib when being fed. During the time in the crib, what is the child most likely to have experienced?

Sensory deprivation Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. Kinesthesia refers to awareness of positioning of body parts and body movement. Stereognosis is the sense that perceives the solidity of objects and their size, shape, and texture. Adaptation occurs when the body quickly adapts to constant stimuli.

The nurse is teaching a class about sexuality at a public health clinic. After class the nurse is approached by Cathleen, a 54-year-old female, who eventually discloses to the nurse that she is having a sexual affair with a female partner. The term for an individual's preference for a partner of a particular gender is which of the following?

Sexual orientation Sexual orientation refers to the preferred gender of the partner of an individual. A transvestite is an individual who desires to take on the role or wear the clothes of the opposite sex. Gender role behavior is the behavior a person conveys about being male or female. A transsexual is a person of a certain biologic gender who has the feelings of the opposite sex.

A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?

Small intestine Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.

A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant?

Supine position The nurse will teach the parents to position the infant on the back (supine). Sleeping in the prone position increases the risk for sudden infant death syndrome (SIDS).

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

Teach client's spouse to keep car keys in an undisclosed location at night. The priority nursing intervention is to prevent the client from experiencing hazardous behaviors while asleep. Driving or taking part in occupational behaviors can lead to accidents; therefore, educating the client's spouse to keep car keys in another location enhances the chance of safety for the client. All other interventions can be undertaken after this.

A client has a nursing diagnosis of body image disturbance related to a recent bilateral mastectomy. Which goal is most appropriate to include in the nursing plan of care?

The client will participate as she is able in the daily care of the incisions. All of these are appropriate goals. However, the only option that relates directly to body image is the care of the incisions daily. By caring for the incisions the client is showing self-care to the extent that she is able.

A nurse on the night shift checks on a client and suspects that the client is in REM sleep. Which client cue is indicative of this stage of sleep?

The client's eyes dart back and forth quickly The nurse would find the client's eyes dart back and forth quickly during REM sleep. The client would have a rapid or irregular pulse. The client's metabolism and body temperature would increase. The client's blood pressure would increase.

Which of these is a situational transition?

The transition from being married to being divorced. Situational transitions are associated with a change in relationships.

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. What kind of pain is the client experiencing?

Visceral pain The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

Which of the following questions would the nurse ask to assess a patient's self-identity during a focused self-concept assessment?

What are your personal strengths? Identifying one's own personal strengths describes a person's self-identity. Self-esteem is assessed by asking the patient who he or she would like to be. Asking the patient what he or she likes most about their body assesses body image. Role performance is assessed by asking the patient about their satisfaction in their job.

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?

Wong-Baker FACES® scale Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or visual analog scale are more appropriate for adults.

Which client would the nurse consider most at risk for sensory deprivation?

a client in an isolation room The client in an isolation room is the most sensory deprived of these clients because this client will have little contact with visitors, and has limited contact with the staff. A client who visits a physician office or emergency department is in contact with several people on the units, as is the long-term care resident.

During a routine physical exam, a male client informs the nurse that he frequently participates in anal intercourse with his new girlfriend. The nurse discusses this practice with the client by informing him that:

condoms are recommended for anal intercourse. Condoms are recommended for anal and vaginal intercourse to prevent sexually transmitted diseases. Care should be used to avoid injury to the delicate rectal mucosa, and lubrication is necessary for comfort.

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is:

condoms. Condoms provide effective (though imperfect) protection against STIs. Spermicides, diaphragms, and cervical caps do not provide effective protection against STIs.

Which activity for rest break should not be incorporated into care planning for clients to aid in healing and recovery?

drinking an 8 oz cup of a caffeinated beverage Drinking a caffeinated beverage is not as energizing as a short 15- to 30-minute nap, stretching exercises, or taking a short walk.

A pediatric nurse understands the concepts surrounding the formation of self-concept and incorporates these concepts into the delivery of her nursing care. Based upon these concepts, when does an individual learn that the physical self is different from the environment?

during infancy An infant learns that the physical self is different from the environment. During this period of time, if the infant's basic needs are met, warmth and affection are experienced. The caregiver's anxiety is minimized, and the child begins life with positive feelings about self.

Which beverage does the nurse recommend to a client with insomnia that may promote the ability to sleep?

milk Milk contains L-tryptophan, a chemical that is known to facilitate sleep. Hot chocolate and cola contain caffeine. The nurse should never recommend alcohol, which is a depressive drug.

The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is:

observe client's hours of sleep and review client's sleep diary. Observing the sleeping patterns and checking the client's sleep diary can lead the nurse to clues about the quality of the client's sleep. Neck circumference can be a factor in obstructive sleep apnea, but it is not routinely measured during assessment. Being overweight is a common finding in sleep disorder clients, but visual acuity issues are not. Auscultation of the lungs and abdomen are not pertinent to the potential disorder.

Which clients, at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? (Select all that apply.)

pregnant teenagers, people with substance abuse problems, older adults living on fixed incomes Examples of those in the United States at risk for an inadequate nutritional intake include older adults who are socially isolated or living on fixed income, homeless people, children of economically deprived parents, pregnant teenagers, people with substance abuse problems, and clients with eating disorders. Children of middle-income parents and individuals who prefer to purchase food from local farmers are not necessarily at risk.

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

providing a backrub with morning and evening care Tactile stimulation includes backrubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation.

In Stage 4 sleep, the:

pulse rate is slow During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth The growth spurt that occurs during adolescence may necessitate the need for more sleep. However, the stresses of school, activities, and part-time employment may cause adolescents to have restless sleep, and many adolescents do not get enough sleep.

The nurse is providing teaching for a postoperative client complaining of nausea. Which food would be the most appropriate to recommend?

saltine crackers The dry crackers are best to help control the nausea. The other foods are too heavy and may increase nausea.

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

sleep paralysis and automatic behavior Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them. This client experiences sleep paralysis and automatic behavior.

The nurse is helping a client with low-fat dietary order to eat breakfast. Which food will the nurse remove from the dietary tray?

whole milk The nurse should remove whole milk from the tray since this has the highest amount of fat in it. The other choices have fewer amounts of fat and may be suitable for this client's diet.