Wellness and illness exam 3
Open fracture
a fracture in which damage also involves the skin or mucous membranes
simple fracture
a fracture that remains contained, with no disruption of the skin integrity
Wheezing is...
a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration
A nasal cannula is...
a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of O2
The changes to the sleep cycle that usually occur in the older adult are an increase in stage I and a decrease in deep sleep. These changes lead to...
a less restful sleep and more frequent awakenings during the night.
What is Pulse oximetry?
a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood
Avascular necrosis is...
a potential complication of a fracture
Volume of air exhaled and inhaled would be performed during...
a pulmonary function test (PFT)
Polysomnography
a sleep study
To ambulate using a walker, the patient should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her...
a wide base of support while she moves forward.
The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?
Acknowledge the pain as the client reports it and administer pain medication as prescribed.
You are caring for a pt who has a long history of using opioid pain medication. Which action will you take to further assess the pt's pain and provide pain relief?
Acknowledge the pain as the pt reports it and administer pain medication as prescribed.
A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?
Activates the receptors for the hormone melatonin
Pain that is more sharp and severe and lasts from 3 to 6 months.
Acute pain
Pain that occurs abruptly after injury or disease.
Acute pain
A pathologic finding and indications of physical dependence are signs of....
Addiction
The fact or condition of being addicted to a particular substance, thing, or activity.
Addiction
A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?
Administer naloxone
The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?
Administer naloxone.
A pt is prescribed pain medication every 4 to 6 hours as needed. When you enters the pt's room to administer the medication, the pt is laughing with visitors. The pt's pulse rate is 64, respirations 16, and blood pressure 120/80. The pt reports pain and wants the medication. What is the most appropriate action?
Administer the pain medication.
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?
Administration of 0.4 mg of naloxone
When using cold pack The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag, why?
Air can block the conduction of cold to the injury.
A structural change that can be found in older adults that cause the lungs to become smaller and less elastic.
Alveoli enlarge and alveolar walls become thinner
You are assessing a pt's respiratory effort and note that the pt's breaths are shallow and 8 per min. Shortly after, the pt's respirations cease. Which form of O2delivery should you use for this pt?
Ambu bag
An open wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall in which the knees are scraped.
An abrasion
You are assessing the vital signs of people in a community health care facility. Which pt respiratory results should you report to the health care provider?
An infant with a respiratory rate of 16 bpm
A tent-like enclosure within which air supply can be enriched with oxygen to aid a pt's breathing
An oxygen tent
How long can each cold application remain in place when used with cast?
Application should last 20 - 30 minutes.
You must obtain a blood specimen for blood gas analysis. What is the most important thing for you to do immediately after the needle has been removed?
Apply steady, firm pressure on the puncture site for 5-15 min.
You are caring for a pt who has a compromised cardiopulmonary system and needs to assess the pt's tissue oxygenation. You would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action?
Ask the client and caregiver for a medication history.
You are a nurse manager and hear a nurse and a nurse aide talking about a female pt who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. She states, "I don't believe this pt has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action?
Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.
What constitutes the assessment of neurovascular status?
Asses circulation, sensation, pain, and movement of distal to injury.
Frequency of assessment in first 24 hours after cast is placed.
Assess every hour for first 24 hr
A pt prescribed pain medication around the clock experiences pain 1 hr before the next dose of the pain medication is due. Which is the most appropriate action by you?
Assess for medication prescription for breakthrough pain.
You caring for a client receiving oxygen therapy via nasal cannula. The pt suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action you should take?
Assess oxygen tubing connection
The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?
Assess the client's vital signs and pulse oximetry.
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.
Nurse caring for immobile pt, which action is the priority to include in the pt's plan of care?
Auscultate breath sounds at least every 2 hours.
The performance of routine tasks without full awareness, or later memory, of having done them.
Automatic behavior
Ways to promote a healthy sleep routine for children.
Bedtime rituals such as: - reading stories - having a healthy carbohydrate snack - holding a favorite stuffed toy - use of a night light
Describe appropriate bedtime snacks.
Bedtime snack: carbohydrate & protein snack
A technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin, transforming the data into a visual display.
Biofeedback
Why is a 2-min rest period is ideal when performing diaphragmatic breathing?
Breaks for periods longer than 2 mins can reduce the momentum of breathing for the pt
A temporary flare-up of moderate to severe pain that occurs even when the pt is taking pain medication around the clock.
Breakthrough pain
It can occur before the next dose of analgesic is due (end of dose pain).
Breakthrough pain
It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis."
Breakthrough pain
You are teaching pt with pulmonary disorder about deep breathing. Pt asks, "Why is it important to start by breathing through nose, then exhaling through mouth?" What response would you give this pt?
Breathing through nose first will warm, filter, and humidify the air you are breathing
Breath sounds that are high, harsh/hollow, low, short during inspiration, long in expiration, and found in the trachea and thorax.
Bronchial
Upon auscultation of the pt's lungs, you hear loud, high-pitched sounds over the larynx. What term will you use in documentation to describe this breath sound?
Bronchial
What type of breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx?
Bronchial breath sounds
You are reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would you most likely identify as an effect of exposure to automobile pollutants?
Bronchitis
Moderate, mixed *harsh and breezy), moderate, equal sounds during inspiration and expiration found over the major bronchi (posterior), between the scapulae (anterior).
Bronchovesicular
What breath sounds are medium-pitched blowing sounds heard over the major bronchi?
Bronchovesicular breath sounds
Air trapping is seen in...
COPD bc air is trapped in the lungs during forced expiration
A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?
CRIES Pain Scale
Why is it a stiffer chest wall a structural change that is observed in older adults?
Calcification of the intercostal cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints.
Occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger.
Cataplexy
You're caring for a pt who has had unrelieved back pain for 3 years. How will you document this type of pain?
Chronic and somatic
What does bronchiectasis result from?
Chronic inflammation or infection causing an excess accumulation of mucus
Comfort Alteration Description: Severe discomfort secondary to stomach cancer
Chronic malignant/cancer
Discomfort that lasts longer than 6 months.
Chronic pain
Pain that is often defined as lasting more than 12 weeks.
Chronic pain
What factor has been hypothesized by researchers regarding current thoughts on sleep?
Chronic sleep deprivation is present.
Why do unfamiliar sounds tend to interfere with the pt's ability to fall or stay asleep?
Clients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces.
The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include?
Close your eyes while practicing the relaxation exercises.
The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?
Closing the client's room door to reduce unnecessary noises
Why is a small protein- and carbohydrate-containing snack such as cheese and crackers about an hour before bed an acceptable snack?
Combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep.
Types of fractures
Complete, incomplete, closed or simple, and open or compound/complex
The client reports back pain and requests medication for the pain. The client is prescribed a placebo. The client believes an opioid is prescribed. What action will the nurse take?
Contact the health care provider.
When you observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40bpm with occasional pauses in breathing of 5-sec duration. What is the most appropriate action?
Continue to assess the infant.
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Corticosteroids
Comfort Alteration Description: Burned hand from touching a hot plate.
Cutaneous
What type of pain will the client experience as a result of the IV placement being preformed?
Cutaneous
Discomfort that originates at the skin level.
Cutaneous pain
Alcohol is known to decrease the amount of...
Delta and REM sleep
Pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso.
Diffuse pain
A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns?
Discuss the sleep pattern with the health care provider.
Describe priority signs and symptoms that should be reported to the provider: (must identify all)
Distal to the cast, report: · numbness, tingling · cool/cold · decrease in ability to move or pain with movement. · pain that is not controlled by medications.
When can a plaster cast be covered with a plastic bag?
Do not cover a plaster cast with a plastic bag unless the cast is dry.
When should diuretics be scheduled?
Do not schedule diuretics at bedtime
Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?
Do you usually go to bed and wake up about the same time each day?
While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?
Document the finding and then position pt to remove any pressure from that area.
While using a pulse oximeter to measure a pt's SpO2 you obtain a reading of 95%. What is your most appropriate action? a. Encourage pt do deep-breathing exercises b. Raise head of bed slightly, if pt tolerates c. Review meds pt has taken in past 90 mins d. Document this expected assessment finding
Document this expected assessment finding
Occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief.
Drug tolerance
If pt experiencing hypoxia, oxygenating pt to bring the pt's oxygen saturation above 90% aims to do what?
Easy the patients work of breathing
Which dietary guideline would be appropriate for the older home-bound pt with advanced respiratory disease who informs you that they have no energy to eat?
Eat smaller meals that are high in protein so body can produce plasma proteins.
Planning care for pt with decrease LOC. Pt receiving cts enteral feedings via gastrotomy tube due to inability to swallow. Which is priority action by nurse?
Elevate head of pt's bed 30-45 degrees
How should the nurse position the head of the bed for a client receiving epidural opioids?
Elevated 30 degrees
Why would raising the head of bed of pt with dyspnea or low SpO2 be appropriate?
Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. Head and neck extended which promotes airway patency.
Why would you elevate the bed of a pt to 30 degrees post an epidural opioid?
Elevation of the client's head minimizes upward migration of the opioid in the spinal cord, thereby decreasing the risk for respiratory depression.
What type of breath sounds are low-pitched, soft sounds heard over the peripheral lung fields?
Vesicular breath sounds
A nurse is caring for pt with pneumonia. Which action will the nurse take to promote thinning of respiratory secretions?
Encourage pt to increase fluid intake
An older adult client reports insomnia. Which interventions can the nurse implement to promote quality sleep for the client?
Encourage the client to empty the bladder at bedtime.
The client had orthopedic surgery 2 days ago. Physical therapy is scheduled in 1 hour. During the nurse's rounds, the client reports postoperative pain as mild and denies needing the prescribed oral pain medication. Which nursing action will best aid in mobilizing the client?
Encourage the client to take a dose of the pain medication now.
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.
What type of sounds over peripheral lung fields and resonance on percussion are expected assessment findings in an older pt?
Vesicular sounds
Performing chest physiotherapy on pt with respiratory infection. To increase velocity and turbulence of air when pt exhales, which technique should be used?
Vibration
Comfort Alteration Description: An inflamed appendix is causing severe right lower quadrant pain.
Visceral
Discomfort that arises from internal organs caused from a disease or injury.
Visceral pain
Pain that originates internally and is the result of stretching, distention, inflammation, or damage to the hollow and solid organs.
Visceral pain
occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis
Visceral pain
You're assessing a pt's respiratory status gets a weak signal from the pulse oximeter. The pt's other vital signs are within reference ranges. What is your best action?
Warm the pt's hands and try again
The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?
Examine the effectiveness of the current pain regimen
While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?
FLACC scale
T/F. A pt with a low Hb level will also have an abnormal SpO2 reading.
False, even a pt with a low Hb level and signs of hypoxia could appear to have a normal SpO2 if most of that hemoglobin is saturated.
T/F. Absent breath sounds are normally found in asthmatic clients
False, they are characteristic of pneumonia
The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?
Find a phone app that plays sounds of the city.
What are crackles?
Frequently heard on inspiration, they are soft, high-pitched discontinuous (intermittent) popping sounds
Used as a diuretic.
Furosemide
Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents?
Getting the child to sleep can be difficult.
Describe proper hand placement with a new cast.
Handle a plaster cast with the palm of the hands until it is dry.
Elderly skin change: Cell renewal is shorter. skin assessments?
Healing time delayed.
A common cause of hyperalgesia.
Herpes zoster
The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?
How does the pain develop and progress?
A 77-year-old woman is on your unit s/p left knee replacement. The pt typically stools every morning but has not had a bm in 3 days. You knows that which medication places the pt at increased risk for constipation?
Hydromorphone
A 54-year-old man is recovering from an outbreak of Herpes zoster on his left chest. He tells the nurse that even his shirt touching him causes a horrible pain on the left side of the chest. What term would best describe the client's pain?
Hyperalgesia
causes fragmented, short-wave sleep stages
Hyperthyroidism
Dream-like auditory or visual experiences while dozing or falling asleep.
Hypnogogic hallucinations
An alteration in a person's state of consciousness so that pain is not perceived as it normally would be.
Hypnosis
A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?
Hypothalamus
You assess a pt and detect the following: dyspnea, tachypnea and tachycardia, and pallor with regions of cyanosis. What condition would you suspect as causing these respiratory alterations?
Hypoxia
Instructing young pt about sleep habits. Which would ID needs more teaching?
I watch tv until i fall asleep
When are cold applications(ice) used when cast placed?
Ice is applied for the first 24 hours. Then warm/cold compressed may be alternated.
Pt with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing.
If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed.
The nurse prepping discharge teaching for a pt with COPD. Which teaching about deep breathing will the nurse include? a. Take in a little air over 10 secs, hold breath 15 secs, and exhale slowly b. Take in a small amount of air very quickly then exhale as quickly as possible c. Inhale slowly over three secs, purse lips, contract abdominal muscles, and exhale slowly d. Take in a large volume of air over 5 secs and hold breath as long as able before exhaling
Inhale slowly over three secs, purse lips, contract abdominal muscles, and exhale slowly
steps for using MDI
Inhaling deeply and then exhaling completely is the first step. Next, the client should place her lips firmly around the mouthpiece to direct the spray to the airways, then breathe in deeply over 2 to 3 seconds while pushing down on the canister. This slow, deep inhalation directs the medication down into the lower respiratory tract. Holding her breath for 10 seconds is next; it allows time for absorption of the medication. Then, pursed-lip breathing keeps the small airways open during slow exhalation. And finally, waiting 60 seconds between puffs allows for deeper penetration of the medication into the respiratory tract.
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? a. Place pt in dorsal recumbent position for specimen collection. b. Have pt clear nose and throat, then gargle with salt water before beginning the procedure. c. Instruct pt to inhale deeply then cough. d. Discard first sputum produced.
Instruct pt to inhale deeply then cough
The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client?
Intractable
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, you notice the mask is no longer fitting properly. Which question should the nurse prioritize?
Is your mask causing discomfort?
Which teaching about the humidifier is important for you to provide to a pt using O2?
It decreases dry mucous membranes via delivery of small water droplets
Which teaching about the oxygen analyzer is important for you to provide to a pt using oxygen?
It determines whether the pt is getting enough oxygen.
When using a manual resuscitation by bag and mask what is expected of the pt's oxygen saturations? Does that indicate that it should stop being used?
It is an expected outcome that the pt's oxygen saturations will increase when using the device, but this is not an indicator that use of the device should end
Why is a face tent appropriate for a pt with facial burns or trauma that has an order for oxygen?
It is used without a mask and is open and loose around the face
Milk contains ____ , a chemical that is known to facilitate sleep.
L-tryptophan
Open wounds of varying depths caused by a tearing of soft body tissues, often with jagged and irregular edges.
Lacerations
Involves exposing the client's eyes to an artificial bright light that simulates sunlight for a specific and regular amount of time during the time the person should be awake.
Light therapy
When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?
Low-flow oxygen
What are Vesicular sounds?
Low-pitched, soft sounds heard over peripheral lung fields
You are suctioning a pt's tracheostomy when it becomes dislodged and you are unable to replace it easily. What's the most appropriate response?
Maintain the pt's oxygenation and alert the health care provider immediately
Acute pain episodes, persistent chronic pain, or both associated with a progressive process.
Malignant pain
What are Bronchovesicular sounds?
Medium-pitched blowing sounds heard over the major bronchi
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.
A pt with hx of COPD has been ordered oxygen at 3 L/min PRN for tx of dyspnea. What delivery mode is most appropriate to this pt's needs?
Nasal cannula
Comfort Alteration Description: A burning severe pain that occurs as the result of herpes zoster (shingles)
Neuropathic
Often experienced days, weeks, or even months after the source of the pain has been treated and resolved.
Neuropathic pain
Pain that arises from damage to the peripheral nerves or the CNS and is the result of abnormal sensory input.
Neuropathic pain
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?
Newborns sleep 16 to 17 hours per day.
What are some examples of parasomnias?
Nightmares, somnambulism, and nocturnal enuresis
You is obtaining a pulse oximetry reading for a pt admitted with exacerbation of COPD. When observing a reading of 89%, what action should you perform?
No action is required, because this may be normal for the pt
What can be placed inside a cast?
Nothing. Never place a foreign object inside the cast.
You must deliver O2 at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?
Oxygen hood
May cover only the nose and mouth and can vary in the amount of oxygen delivered.
Oxygen masks
Allow the pt to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense.
PCA pumps
This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. This drug delivery system may be used to manage acute and chronic pain in a health care facility or the home.
PCA system
A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?
PRN order
Which principle should the you integrate into the pain assessment and pain management of pediatric pts?
Pain assessment may require multiple methods in order to ensure accurate pain data.
A pt is prescribed pain medication every 4 to 6 hours as needed. When you enters the pt's room to administer the medication, the pt is laughing with visitors. The pt's pulse rate is 64, respirations 16, and blood pressure 120/80. The pt reports pain and wants the medication. Why is it appropriate to give the medication even though all v/s are w/in normal limits?
Pain is present whenever the client perceives being in pain.
Using a PCA pump the pain relief is...
Pain relief is rapid because the drug is delivered intravenously.
What're the 5P's?
Pain, pulse, paresthesia, paralysis, and pallor
What effects of hypnotics involve a stimulating effect or mental changes?
Paradoxical effects
associated with activities that cause arousal, or partial arousal, usually during transitions in NREM periods of sleep.
Parasomnias
When the body becomes accustomed to an opioid and needs a larger dose each time for pain relief it is not a...
Pathologic finding and does not necessarily indicate physical dependence.
An abnormal pain-signaling process with origins that can occur both peripherally and centrally.
Persistent pain
Comfort Alteration Description: Severe pain perceived to be originating from the right foot (Amputated three years ago).
Phantom
A pt is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The pt has a barrel chest and clubbed fingers. What is your priority intervention?
Place pt in the tripod position
You are assigned to care for a pt admitted to the health care facility with the diagnosis of atelectasis. When interviewing the pt, you would anticipate a history of:
Pneumonia
Avoiding large crowds and practicing good hand hygiene will have what effect?
Prevent respiratory infections
You're preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?
Preventing constipation
A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?
Provide an opportunity for the client to talk about concerns.
You provide care for a pt with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would you take next?
Provide oxygen for consistent hypoxia
Comfort Alteration Description: Pain rated as 8 out of 10. No physical cause for the pain can be identified.
Psychogenic
Regarding LOC, what is a sign of normal oxygenation?
Pt is oriented to day, time, and place indicating an intact level of consciousness
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Pulmonary function tests
Nurse caring for pt returning postop. Pt's SpO2 is 85%, which action should nurse take first?
Raise head of bead
A selective melatonin receptor agonist prescribed to facilitate the onset of sleep
Ramelteon
Comfort Alteration Description: Jaw pain association associated with occluded coronary artery.
Referred
Nurse auscultating a pt's lung sounds and ID's crackles in the LLL. Which intervention should nurse take?
Repeat auscultation after asking pt to breath deeply and cough.
Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take?
Reposition the client and gently massage the client's back.
During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called...
Residual Volume (RV)
You schedule a pulmonary function test (PFT) to measure amount of air left in pt's lungs at max expiration. What test do you order?
Residual Volume (RV)
A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?
Respiratory depression
What does RICE stand for?
Rest, Ice, Compression, and Elevation
Stimulants that should be restricted before bedtime.
Restrict 4-6 hrs before bedtime 1. caffeine 2. nicotine 3. alcohol
How should a walker be positioned so pt can ambulate?
She should stand in the center of the walker and grasp the handgrips on either side, with her elbows bent about 30°.
Elderly skin change: Collagen fiber is less organized. Skin assessments:
Skin loses elasticity
Is believed to play an important role in reducing fatigue, stabilizing mood, and improving blood flow to the brain, among other things.
Sleep
A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?
Sleep Deprivation
The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:
Sleep Pattern Disturbance related to acute pain.
Occurs when the person cannot move for a few minutes just before falling asleep or awakening.
Sleep paralysis
Comfort Alteration Description: Pain rated as a 9 out of 10 associated with a broken ankle.
Somatic
You are assessing the pain of a pt who has been diagnosed with a sprained ankle. The pt describes the pain as aching and is able to identify the pain as occurring in his left ankle. You identify this as which type of pain?
Somatic
Pain that originates in bone, skin, and soft tissue and is often well localized.
Somatic pain
Easy arousal from sleep and involuntary muscle jerking that may awaken the client are signs...
Stage I NREM.
The client's pulse, respirations, and blood pressure decrease, and muscles are relaxed are signs of...
Stage IV NREM
The air quality index (AQI) has rated it a red air quality day in the city. Which information will you share with the pt about promoting effective respiratory self-care?
Stay indoors as much as possible
Sputum in the trachea produces what sound?
Stridor
A noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers.
TENS
T/F. Application of TENS is not delegated to UAP. Opioids do not contraindicate the use of TENS and there is no associated risk of electrocution.
TRUE
Assessing pt who has hypoxia. Which finding should nurse expect?
Tachycardia
During the apneic or hypopneic periods, ventilation decreases and blood oxygenation drops and...
The accumulation of carbon dioxide and the fall in oxygen cause brief periods of awakening throughout the night.
What team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min while being treated with epidural analgesia?
The anesthesiologist/pain management team
The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?
The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.
Discharging pt who needs home oxygen therapy, which statement indicates pt needs more teaching?
" I will wear synthetic clothing and woolen socks when using oxygen."
A nurse is instructing her students on the role of hormones in sleep patterns. Which statement would indicate to the nursing instructor that the student needs additional education?
"A hyperactive thyroid can make the client sleepy all the time."
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as...
"Acute pain tends to increase during the day and is called a routine pain response"
Why might a cast become loose?
The cast could become too loose as the swelling subsides.
When inspecting a pt's chest to assess respiratory status, you should be aware of which normal finding?
The chest should be slightly convex with no sternal depression.
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?
The child should limit fluids after supper.
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
"Can you describe the type of pain you are having?"
A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?
"Create a bedtime routine."
The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?
"How long have you experienced this pain?"
t After you have instructed a pt with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, you determines that the pt has a need for further instruction when the pt states what?
"I could use the TENS unit if I feel pain somewhere else on my body."
The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance?
"I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart."
You are teaching a pt how to manage postoperative pain through a patient controlled analgesia (PCA) pump. You determines that additional teaching is needed when the pt make which statement?
"I should only take medication when my pain is intense."
The nurse awakens a client while the client is experiencing rapid eye movement sleep. What statement made by the client indicates they were awakened during REM sleep?
"I was having a great dream and I remember all of it."
The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?
"I will record the time I go to bed and how long it takes me to fall asleep."
A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?
"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."
A hospitalized client informs the evening shift nurse about not being able to sleep without a shot of whiskey each night before bed and asks if the spouse can bring in a bottle. Which is the best response by the nurse?
"Let's discuss that with your health care provider."
A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?
"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."
A client asks the nurse if hot chocolate at bedtime will improve the client's sleep. Which is the best response by the nurse?
"Milk is a better option to help you sleep."
The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?
"My boys love to roughhouse in their room right before bedtime."
While caring for a pt with chronic pain, you talk with a family member. Which family member statement do you identify as consistent with caregiver role strain?
"Sometimes it seems like I can never get a moment to myself."
A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?
"The CPAP assures you get enough oxygen throughout the night."
You're assessing a pt who is experiencing pain. You notes the pt is experiencing acute rather than chronic pain when the pt makes which statement?
"The pain is really sharp in this one spot."
A pt has been prescribed patient-controlled analgesia (PCA) and you are setting up the system and educating the pt about safe and effective use of PCA. Which teaching point should you provide to the pt?
"The pump is programmed with safeguards to limit the possibility overmedication."
An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?
The client exhibits restless, uncharacteristic behavior after receiving the drug.
A PRN order is one that is given to a client on an....
"as needed" basis.
What does FLACC, in The FLACC scale of pain, stand for?
(face, legs, activity, cry, and consolability)
A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?
The client is actively involved in pain management.
When ambulating with a walker, what is the proper way for pt to step forward?
The client should move the walker first, then move one foot up to the walker while bearing weight on the other foot and both arms, then move the other foot forward with the weight on the first foot and both arms.
A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?
The client will likely not be able to sleep.
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
A pt has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?
The dose that is delivered when the pt activates the machine is preset.
Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions.
The gate-control theory
After you have instructed a pt with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, you determines that the pt has no need for further instruction when the pt makes what statements?
- "One advantage of the TENS unit is it increases blood flow." - "I may need fewer pain medications with the TENS unit in place." - "Wearing the TENS unit should not interfere with my daily activities."
Normal breathing
- 10-20bpm - regular
Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you expect to be ordered as therapy?
- A walking aid - Acupuncture - Physical therapy referral
potential source of skin alteration: side rails. Name nursing interventions..
- Assess bed mobility - Avoid positioning the patient close to siderails - Position pillows between siderail and pt. - Secure padding (towels) to siderails
You're caring for a pt who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate?
- 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.
Elderly skin change: Cell renewal is shorter. Nursing interventions:
- Assess wounds, lesions for healing Monitor for s/s skin breakdown - Protein & fluid intake each meal - Aggressively prevent/treat areas of skin breakdown - Teach: s/s infection; early signs of skin injury; rationale for diet
What're examples of implementation of physical adjustment techniques to promote comfort?
- Assisting the client to change positions - Smoothing out wrinkles in the bed linen
When inspecting an adult pt's chest to assess respiratory status, what are considered normal findings?
- Chest contour is slightly convex, with no sternal depression - The skin of the thorax should be warm and dry - The anteroposterior diameter of the chest should be less than the transverse diameter - The contour of the intercostal spaces should be flat or depressed
Relaxation techniques..
- Closing the eyes will help the client focus on relaxation and not be distracted by visual cues. - The client should assume a comfortable position - The client takes deep abdominal breaths, not shallow breaths, to promote relaxation. - The client would tighten and relax muscles, starting with the toes and working up towards the head.
The young female pt had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would you include when providing discharge teaching?
- Do not drive a vehicle while taking this medication (due to slowed reflexes and decreased cognitive thinking). - You must check with your primary care provider before breast-feeding your infant (meds absorbed into breast-milk and can cause adverse effects for baby). - Keep a diary to record level of pain and time medication is taken (provides accurate documentation of pain and prevent overdose). - The client is not to drink alcohol (EtOH depresses CNS system if taken with opioid and lead to respiratory failure). - If pt smokes and wont stop, then someone needs to supervise in case falls asleep. - Take with food to prevent nausea.
A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client?
- Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. - Eat a small snack of protein and carbohydrate before bedtime. - Discuss the use of a sleep aid with the health care provider.
Which examples of pain response are affective responses to pain?
- Exaggerated weeping - Restlessness
Elderly skin change: Thinning of subcutaneous and dermal skin. Nursing interventions:
- Focused assessment of pressure areas - No tape; Pad bony prominences - Pad side rails, foot board - Toe Pleat - Teach: Check skin daily, report areas of skin breakdown that do not heal in a timely manner
The nurse is planning care for clients to aid in healing and recovery. Which activity(ies) will the nurse recommend they incorporate into a rest break?
- Focusing thoughts on a pleasant scene - Taking a short 15- to 30-minute nap - Stretching exercises - Going for a short walk
potential source of skin alteration: Foley catheter. Name nursing interventions..
- Frequent skin checks - Frequent repositioning of tubing - Reposition foley drainage tubing with each repositioning pt every two hours
A client reports periodic difficulty falling asleep. Which teaching will the nurse provide?
- Go on a daily walk. - Adhere to a regular schedule for waking and going to sleep. - Decrease caffeine intake.
Elderly skin change: Melanocytes decline in number. Skin assessments:
- Hair becomes gray-white. - Skin may be unevenly pigmented.
You are administering oxygen to an older pt who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will you expect on the evaluation of the client?
- Heart rate is 64 beats/min. - Mucous membranes are pink and moist - The client is able to state the date, time, and location - Oxygen saturation above 90%
The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain?
- How do you rate your pain on a scale of 0 to 10? - Does anything make the pain worse? - How would you describe the pain? - When did your pain begin? - What medication have you taken to relieve the pain?
Which examples of pain response are physiologic responses to pain?
- Increased blood pressure - Muscle tension and rigidity
The nurse prepares the client for a 12-lead electrocardiogram (ECG). Which actions should the nurse provide? Select all that apply.
- Instruct the client to relax arms away from waist and legs not touching the foot-board. - Prepare skin, removing excess oil and clip areas of excessive hair. - Place self-stick electrodes and place according to anatomical locations. - Explain that the client needs to lie still and not talk during the ECG recording.
While overseeing the care of a pt who is receiving oxygen via nasal cannula, which aspects of the pt's care can you safely delegate to unlicensed assistive personnel (UAP)?
- Measuring the client's respiratory rate - Reapplying the client's nasal cannula after a bath - Inserting the client's nasal cannula after it has become dislodged
potential source of skin alteration: Cast, brace, splint. Name nursing interventions..
- Monitor for areas of irrtitation - Cover edges with soft material - Do not insert anything into cast - Report drainage, odor - Monitor perfusion distal to the cast - Monitor cast fit (not too tight, not too loose)
Elderly skin change: Decrease in sebaceous and sweat gland function. Nursing interventions:
- Monitor for dryness, tears, irritation, breakdown - Maintain hydration - Avoid daily total body baths: bath perineal area daily - Apply lotion daily - Drink at least 2000 ml of fluid/day
potential source of skin alteration: oxygen delivery device: nasal cannula; facemask . Name nursing interventions..
- Monitor skin for irritation & breakdown around device - Monitor for skin irritation above ears - Monitor for skin irritation inside nostrils. - Lubricate nostrils with water soluble lubrican
Risk factors for the development of atelectasis.
- Prolonged bedrest with few changes in position - ineffective coughing - underlying lung disease
A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep?
- Promoting daytime exercises - Providing a back massage - Assisting with progressive relaxation
Which examples of pain response are behavioral responses to pain?
- Protecting the painful area - Grimacing and moaning
What are some factors that indicate you should stop delivery of breaths via a manual resuscitation bag and mask device?
- Pt has a return of spontaneous breathing at 15bpm - Pt has been intubated and is connected to a mechanical ventilator - HCP has ended CPR efforts
When you are caring for a pt with a chest tube what should be monitored?
- Pt's respiratory status - Vital signs - Check the dressing - Maintain the patency and integrity of the drainage system
Assessing pt who has hypoxia. Which findings should nurse expect?
- Rapid, shallow respirations and dyspnea - restlessness and agitation - cyanosis in late stages - tachycardia
potential source of skin alteration: Restraints. Name nursing interventions..
- Remove and assess skin frequently - Maintain two finger breadth circumference - Monitor circulation distal to restraint - Secure restraint to bedrai
Elderly skin change: Melanocytes decline in number. Nursing interventions:
- Skin check for skin cancer (melanoma) - Report suspicious skin lesions to provider - Teach s/s of melanoma. - Use sunscreen.
Signs of hypoxia
- Tachypnea - Tachycardia - Dyspnea - Pallor - Regions of cyanosis
Identify times (after the cast is dry) that a plastic bag should be used to cover a cast. Name two.
- The cast can be covered with plastic to prevent soiling from urine or feces. - cast with a plastic bag when bathing or in shower.
What should a pt going in for a polysomnography expect?
- The client will be scheduled for the study at a health care center and sleep overnight as part of the study. - The client should avoid sedatives, as this will aggravate OSA. - Interventions for OSA include inserting an oral appliance or applying a facial mask for continuous positive airway pressure.
caring for pt who needs cold ice packs to reduces swelling and pain from ankle injury. which action should nurse take?
- The nurse should leave the bag in place for 20 min, but should check the client's skin after 15 min to make sure there are no adverse effects. - After removing the ice bag, the nurse should not reapply it any sooner than 1 hr later. - The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag - The nurse should place a towel, the bag's cover material, or a pillowcase between the ice bag and the client's skin.
potential source of skin alteration: bedrest. Name nursing interventions..
- Turn and reposition in bed every two hours. - Pad boney promininces with pillows or wound dressing material. - Use a drawsheet to reposition patient in bed
Recommended guideline for determining suction catheter depth when suctioning an endotracheal tube?
- Use suction catheter with centimeter increments on it - Insert suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align - Insert the suction catheter no further than an additional 1 cm - Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm - Using a spare endotracheal or tracheostomy tube of the same size as being used for the pt, insert the suction catheter to the end of the tube - Note the length of catheter used to reach the end of the tube
Steps of ambulating with cane...
- When the client moves, he should first move the cane forward about 30.5 cm (12 in). - Then, he should move the weak leg even with the cane. - Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.
The nurse is providing client education for the parents of an obese child diagnosed with obstructive sleep apnea. What treatment measures would the nurse explain during the education session?
- a weight loss plan - use of a continuous passive airway pressure (CPAP) machine - use of a mandibular advancement device (MAD)
The client reports back pain and requests medication for the pain. The client is prescribed a placebo. The client believes an opioid is prescribed. What actions are inappropriate in this situation?
- administering the placebo - would continue the deception which is unethical. - Inform the client of the deception - would cause mistrust
What assessments would you make when auscultating the lungs?
- air flow through the respiratory passages - listen for normal, as well as abnormal, breath sounds
Elderly skin change: Decrease in sebaceous and sweat gland function. skin assessments?
- becomes dryer. - Pruritus (itching) may occur.
Pain management of a pt with respiratory disorder will increase pt participation in ...
- coughing and deep breathing - frequent position changes - incentive spirometer
Eventually, sleep deprivation affects the person's life:
- damaging work productivity - personal relationships
hypoventilation
- decreased rate - decreased depth - irregular pattern - usually associated with narcotics or anesthetics
Elderly skin change: Collagen fiber is less organized. Nurse interventions:
- decreased skin elasticity - Assess for skin tears - Promote bed mobility - fall prevention strategies. - Protect skin from injury. - High protein diet
Pts with hypersomnia should avoid:
- driving an automobile - alcohol - caffeine - late-night activities.
Elderly skin change: Thinning of subcutaneous and dermal skin. skin assessments?
- easily injured - less capacity to insulate - wrinkles easily - Sensation of pressure/pain reduced
What physiological signs would be noticed in a pt in REM sleep?
- eyes dart back and forth quickly - rapid or irregular pulse - metabolism and body temperature would increase - blood pressure would increase
Emergency Management of a fracture
- immobilize body part - splint extremity - assess neurovascular status before and after splinting - if fracture is open then cover with sterile dressing - don't attempt to reduce fracture
A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)?
- increased blood pressure - increased pulse - increased respiratory rate
hyperventilation
- increased rate - increased depth - usually occur with extreme exerise, fear, or anxiety - causes include disorders of the CNS, overdose of the drug salicylate, or severe anxiety
bradypnea
- less 10bpm - regular - can be normal in athletes - can occur with medication-induced depression of the respiratory center, diabetic coma, or neurologic changes
The nurse will educate the client about periods of difficulty falling asleep by recommending sleep-promoting nursing measures, such as:
- maintaining sleep rituals - reducing the intake of stimulating chemicals - promoting daytime exercise - adhering to a regular schedule for retiring and awakening
Forced expiratory volume (FEV)
- measures amount of air exhaled in the first sec after full inspiration - it can also be measured at 2-3 secs
Tachypnea
- more than 24bpm - shallow - can be noraml respnse to fever, anciety, or exercise - can occur with respiratory insufficiency, alkalosis, pneumonia, or pleurisy
Some risk factors for sleep apnea?
- periods of apnea - obesity -cardiovascular disease
Providing preop teaching and demonstrating diaphragmatic breathing to pt who is having sx in the AM. Which action should nurse include in presentation?
- place hands palms down on border of ribcage - inhale slowly and evenly through nose until chest expansion is maximized - hold breath for 2-3 secs - exhale forcefully through mouth
kussmaul breathing
- rapid - deep - labored - type of hyperventilation associated with diabetic ketoacidosis
Medical management of fracure
- reduction - immobilization - tx to prevent infection if fracture is open
Cheyne-strokes respiration
- regular patter characterized by alternating periods of deep, rapid breathing followed by periods of apnea
What structural changes to the respiratory system should you observe when caring for older pts?
- respiratory muscles become weaker - the chest wall becomes stiffer - the ribs and vertebrae lose calcium - the lungs become smaller and less elastic
A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find?
- smokes 1 pack of cigarettes daily - drinks coffee with all meals - history of hyperthyroidism
During REM sleep:
- the client's temperature, pulse, blood pressure, and respirations increase. - The client may experience small muscle twitching, such as facial muscles twitching, - irregular pulse rate and respirations.
In Stage 4 sleep, the:
- the muscles are relaxed, but muscle tone is maintained - respirations are even - blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.
What are some functional changes to the respiratory system in older adults?
-Diminished coughing and gag reflexes -Increased use of accessory muscles for breathing - Increased mouth breathing and snoring
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which actions best ensures a usable specimen?
-Instruct pt to inhale deeply and cough -If any sputum results then collect in container -Place pt in semi-Fowler's position - instruct pt to clear nose and throat, then rinse throat with water.
Manifestations of Fractures
-Pain - Loss of function - Deformity - Shortening of the extremity - Crepitus - Local swelling and discoloration - Diagnosis by symptoms and radiography - Patient usually reports an injury to the area
Biot's respiration
-irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea
Neonates
0 to 6 months
A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?
1
The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of nonrapid eye movement (NREM) sleep, which the client exhibits as Stage:
1
The client should perform the diaphragmatic exercise for ___ and then rest for at least ___ before repeating.
1 full min: 2 mins
A nasal cannula is used to deliver from...
1-6 L/min of oxygen
Identify 3 routines a client can use to promote sleep
1. Establish and maintain bedtime rituals: a warm shower or bath; reading, listening to music; relaxation exercises 2. Go to bed and wake up at the same time. 3. Napping: Keep naps short, less than 30 minutes.
If the tracheostomy becomes dislodged and is not easily replaced, you should...
1. Notify the primary care provider immediately 2. Cover the tracheostomy stoma 3. Assess pt's respiratory status
Identify teaching indicated related to the use of the bedroom.
1. Only go to bed when tired. 2. If unable to sleep after 20 minutes, read in another room. 3. Remove work items and TV from the bedroom 4. The bedroom should be associated with sleep and sexual activity only.
Identify strategies related to health and well-being used to promote sleep.
1. Regular exercise; Complete exercise at least 3 hours before going to bed. 2. Eat a healthy diet 3. prevent/treat pain before becomes severe. 4. Avoid mental/physical stimulating activities after 5PM 5. Cell phone: · Avoid cell phone use after 5PM · Remove cell phone from bedroom · Turn cell phone off or set to "silent"
Identify 3 interventions a nurse can use Interventions to minimize waking a sleeping client.
1. Schedule vital signs, accuchecks, blood draws for same time 2. Adjust time for bathing to match client's home routines 3. Administer medications with other procedures when feasible
List 3 nursing interventions used to simulate normal environment when hospitalized.
1. lighting: brighter lighting daylight; darker lighting night; IV pumps turned, monitor lights dimmed. 2. Noise: Close the door, TV & radio off, decrease volume devices used( pumps, monitors) 3. Keep room at a comfortable, cool temperature
The normal respiratory rate for an adult 65 years and older is...
16-24 bpm
What is the normal respiratory rate for a child 6 to 12 years of age?
18-26 bpm
In an older pt what is considered a normal RR? a. 25bpm b. 8bpm c. 50bpm d. 18bpm
18bpm
A pt is learning how to do diaphragmatic breathing. For which length of time will you advise the pt to rest between repetitions of the exercise?
2 mins
The FLACC scale is used for infants and children of what age?
2 months to 7 years
If the pt's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is?
2.5 L/min
The normal respiratory rate range for a child age 1 to 5 years is....
20-32 bpm
The infant's normal respiratory rate is...
20-40 bpm
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation. What would be the sedation score for this client?
3
The Wong-Baker Faces Pain Rating scale requires children to be at least
3 years old.
Atelectasis refers to...
The partial or complete collapse of the small air sacs in the lungs
You are caring for a pt with emphysema. A review of the pt's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. You would question which prescription if prescribed by the health care practitioner?
4 L/min O2 (66 mL/sec) nasal cannula
If the pt's stroke volume is 80 mL and heart rate is 65 beats per minute, then the cardiac output is?
5.2 L/min
If the pt's stroke volume is 60 mL and heart rate is 95 beats per minute, then the cardiac output is?
5.7 L/min
Chronic pain is discomfort that lasts longer than....
6 months
If the pt's stroke volume is 90 mL and heart rate is 70 beats per minute, then the cardiac output is?
6.3 L/min
You're preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?
80 -150 mm Hg
In practice, the oxygen saturation range of ________ is generally acceptable for most clients, so an oxygen saturation level of 91% is not within a normal, acceptable range and the pt is experiencing hypoxia.
92-100%
What is considered normal oxygen saturation (SpO2?
95-100%
You take a pt's pulse oximetry reading and finds that it is normal. What does this finding indicate?
The pt's available hb is adequately saturated with oxygen.
What type of reaction would an individual with bronchitis when exposed to irritants such as air pollution and high humidity?
The release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production
A cancer pt's care plan includes the use of a transcutaneous electrical nerve stimulation (TENS) unit. Which action should be included in the plan?
The unit should be turned off whenever repositioning the electrodes.
Technique that involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.
Therapeutic Touch
The nurse is assessing a client and determines that they are in rapid eye movement (REM) sleep. What finding indicates to the nurse that the client is in this stage?
There is rapid eye movement under the eyelids.
The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?
They bind to opioid receptor sites throughout the CNS.
Describe a neurovascular assessment...
This consists of assessing the involved extremity (ex. the lower leg) at the most distal point (ex. the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."
Does not indicate addiction or a heightened risk of addiction.
Tolerance
T/F. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.
True
T/F. Acetaminophen is not linked to constipation.
True
T/F. Acute pain may be associated with anxiety and fear.
True
T/F. After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True
T/F. Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia.
True
T/F. Clients should be encouraged to quit smoking, not just cut down.
True
T/F. During closed reduction of a fracture the skin doesnt have to be broken.
True
T/F. Except in the case of infants, fine crackles always constitute an abnormal assessment finding.
True
T/F. Eyes dart back and forth quickly during REM sleep.
True
T/F. 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.
True
T/F. Health care providers are using the term persistent pain in place of chronic pain to help avoid the negative and often inaccurate assumptions associated with chronic pain pts.
True
T/F. It is appropriate to administer pain medication prior to an activity that would produce an increase in pain. If the client takes the pain medication now, there is adequate time for the medication to be absorbed and metabolized. The client will then be better able to participate in the physical therapy exercises.
True
T/F. It is often necessary to use more than one technique for pain assessment in children.
True
T/F. Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.
True
T/F. Muscular jerking, regular respiration, and transitioning to wakefulness are not indicative of REM sleep
True
T/F. Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night.
True
T/F. Observing the pt's behavior is not an appropriate nursing intervention for a pt's pain complaints, as pain is a self-reported finding.
True
T/F. PCAs are designed to make it impossible for the client to exceed the pt-specific dosing parameters programmed into the machine.
True
T/F. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics.
True
T/F. Pts must be cognitively and physically capable of using the PCA equipment safely.
True
T/F. Research has shown that treatment bias may delay pain-relieving measures.
True
T/F. Somnambulism is commonly seen in children.
True
T/F. Stiffer lungs are at higher risk of collapse.
True
T/F. Stress and anxiety interfere with a person's ability to relax, rest, and sleep.
True
T/F. The elderly sleep less soundly for less time, and have little or no Stage IV deep sleep. It is common for them to be confused upon awakening, which could lead to injury.
True
T/F. The growth spurt that occurs during adolescence may necessitate the need for more sleep.
True
T/F. The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. As such, injury to the hypothalamus may cause a person to sleep for abnormally long periods.
True
T/F. The pattern of frequent arousals seen in people with chronic obstructive pulmonary disease may result from the body's adaptation to maintain adequate oxygenation.
True
T/F. The phantom pain is real pain and should be treated as such.
True
T/F. during an open reduction the medical staff performs surgery
True
T/F. stage 3 sleep phase have entered the early phase of deep sleep. They may snore and will exhibit relaxed muscle tone with little or no physical movement. They are difficult to arouse.
True
T/F. •Testing for crepitus can produce further tissue damage and should be avoided.
True
T/F.Insomnia and hypersomnia are often manifestations of depression in older clients.
True
T/f. Immobilization of a fracture can be done either internal or external fixation
True
T/f. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.
True
T/F. Palliative care is not limited to end-of-life care
True.
You auscultate the lungs of a pt with asthma who reports shortness of breath, sore throat, and congestion. Which finding do you expect to document?
Wheezing
You're a nurse educator presenting a lecture on the respiratory and cardiovascular systems. Which response given by the students would indicate to you that they have an understanding of cardiac output?
When calculating cardiac output, multiply the pt's stroke volume and the HR
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?
When obtaining patient vital signs
Nurse at extended-care facility instructing class of assistive personnel (AP) about pt use of assistive devices during ambulation. Which instruction should be given about use of cane?
When pt moves, should move cane forward first
Which client could be diagnosed with narcolepsy?
A 20-year-old man who is reporting excessive drowsiness at work to the point that he falls asleep while at his computer. He goes to bed at 11 p.m. and wakes up at 7 a.m. without difficulty. Twice in the last year he passed out after getting extremely angry.
Which client could be diagnosed with sleep-disordered breathing
A 40-year-old obese man who is reporting fatigue. He states that he goes to bed around 9 p.m. every night and wakes up between 5 and 6 in the morning. He feels like he gets a good night's sleep, but his wife says that she constantly has to poke him throughout the night because he "stops breathing."
Which client could be diagnosed with insufficient sleep syndrome?
A 45-year-old woman who has been reporting fatigue for the last year. When asked about her sleep schedule, she states that she usually goes to bed around 1 a.m. and gets up at 7 a.m. when her 5-year-old daughter gets up. She describes herself as a night owl.
Which client could be diagnosed with insomnia?
A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m.
Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?
A chronic opioid therapy plan
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?
A client who has a sprained ankle
A nurse is caring for four clients. For which client would the nurse request a referral to palliative care?
A client with hypertrophic cardiomyopathy and heart failure
Which medical client is most likely to be experiencing diffuse pain?
A client with shingles affecting her entire torso
A closed wound; the result of a blunt force impact.
A contusion
Closed wound that appears ecchymotic (bruised) as a result of trauma to the vascular system.
A contusion
If pt receiving at home oxygen therapy and finds it hard to concentrate, why should contact HCP?
A decrease in the ability to concentrate could indicate that the client is not receiving enough oxygen.
A reaction between two (or more) drugs or between a drug and a food or beverage.
A drug interaction
Describe stridor.
A harsh, noisy squeak when something is blocking the airway
A device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril.
A nasal cannula
Why is ambulation important to prevent build up of respiratory secretions?
With inactivity, secretions can pool in the airways, diminishing breath sounds, and causing crackles and dyspnea.
You are caring for a pt who is receiving continuous oxygen at 3 L/min via nasal cannula. The pt's oxygen saturation has consistently been 94- 96%, but suddenly drops to 86% as you palpates the pt's abdomen. The pt denies respiratory difficulty or other distress. What is a likely reason for the pt's decreasing oxygen saturation?
You have inadvertently stepped on the pt's oxygen tubing, occluding the flow of oxygen.
What is the appropriate action after giving pain medication to a pt?
You should reassess the pain in 30 after giving the pain medication.
Statement that accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve pt pain?
A pump mechanism that can be programmed to deliver a specified amount of analgesic within a given time interval.
Open wound usually caused by a sharp object that penetrates the skin leaving a small surface opening.
A puncture
Air passing through narrowed airways produces what type of sound?
A wheezing sound
A pneumothorax is...
a collapsed lung
Hemothorax is...
a collection of blood in the space between the chest wall and the lung
What is hypoxia?
a condition in which an inadequate amount of oxygen is available to cells
An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include:
a decrease in the deep sleep stage of the sleep cycle.
An O2 analyzer is...
a device that measures percentage of delivered O2 to determine if pt is getting the amount prescribed
A humidifier is...
a device that produces small water droplets and may be used during O2 administration because O2 dries mucous membranes
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
Using a sedation scale, S is used to document that the client is...
sleeping but easy to arouse.
Somnambulism
sleepwalking
As the client is ambulating, the nurse should walk....
slightly behind her and toward her side in case she needs assistance.
The adult chest contour is...
slightly convex, with no sternal depression
Using a sedation scale, 2 is used to denote that the client is....
slightly drowsy but easy to arouse.
Stage 4 sleep is...
slow-wave sleep
Examples of ____ include soft tissue injury such as a contusion from a sprained ankle.
somatic pain
Using the sedation scale, 4 describes a client who is...
somnolent, with minimal or no response to physical stimulation.
Acute pain is....
specific and localized
A client begins snoring and is sleeping lightly. The stage of sleep is:
stage 2.
The nurse is caring for a client who must receive medication overnight. As the nurse prepares to administer the medication, the client is noted to have relaxed muscle tone, is not moving, snores, and is difficult to arouse. How will the nurse document this stage of sleep?
stage 3
Caregiver role strain may be exhibited by...
statements of exhaustion, frustration, or seeming overwhelmed.
According to the gate-control theory, 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
Auscultating an immobile patient's breath sounds will determine pt's need for...
suctioning
incisional surgical wound infection is described as...
superficial and located above the deep fascia layer
Increased WOB during respiratory distress will cause...
tachycardia and tachypnea
Using the air quality index (AQI), a red color designation signifies...
that the air quality is unhealthy for all people, not just sensitive groups
Ambulation prevents...
the accumulation of respiratory secretions
Arterial blood gases determine...
the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids
Bronchitis refers to a condition in which...
the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity
Total lung capacity (TLC) is...
the amount of air contained within the lungs at max inspiration
In cases of pneumonia, the lungs stiffening means that...
the amount of space available for gas exchange in the lungs decreases
modulation is the phase of pain during which...
the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience.
To assess the quantity of the pain...
the client could be asked to rate the pain on a scale of 0 to 10.
The Trendelenburg position is when...
the feet are higher than the head.
Reverse Trendelenburg position or supine position is when...
the head is higher than the feet.
Prolonged bed rest can result in....
the incomplete lung expansion and collapse of alveoli that characterize atelectasis
Arterial blood gases include...
the levels of oxygen, carbon dioxide, bicarbonate, and pH
Pneumonia causes...
the lungs to swell and stiffen
Older adults may experience adverse effects from analgesics more often than younger adults. Therefore, What information is it a priority to ask about?
the medication history
The gate-control theory provides.....
the most practical model regarding the concept of pain
To assess the quality of the client's pain...
the nurse could ask for the client to describe the pain.
To assess the alleviating factor of the pain...
the nurse could ask what the client does to alleviate the pain and how well it works.
Coarse crackles heard on auscultation indicate...
the presence of fluid in the lungs
While auscultating a pt's chest, you auscultate crackles in the lower lung bases. What condition do you identify the pt is experiencing?
the presence of fluid in the lungs
What does perfusion refer to?
the process by which oxygenated capillary blood passes through body tissues
You're caring for a pt with cancer who is experiencing pain. What would be the most appropriate assessment of the pt's pain?
the pt's pain based on a pain rating
The pain assessment tool should reflect....
the pt's specific circumstances, abilities, and development.
Presence of edema would be assessed as part of...
the pts cardiovascular status
Palliative care focuses on...
the relief of physical, mental, and spiritual distress.
Asthma causes what reaction in the airways?
the small airways become inflamed and narrowed
Transmission is the phase of pain during which...
the stimuli move from the peripheral nervous system toward the brain.
When ambulating with a cane, pt should hold it on...
the strong side of the pt's body.
Tidal volume (TV) refers to...
the total amount of air inhaled and exhaled with one breath
Where should grip be level when pt is using cane?
the trochanter of the femur allowing proper degree of bend in pt's arm (approx 30degree)
If pt's not breathing with an adequate rate and depth, or if pt has lost the respiratory drive...
then a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until pt is resuscitated or can be intubated with an endotracheal tube
A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:
they may be disoriented on awakening.
The idea of the biofeedback technique is that...
through seeing the pain responses, the pt is taught to regulate his physiologic response and control pain.
Pts describe neuropathic pain as....
tingling, itching, burning, cold, prickly, or "shock-like."
The best interview question for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern would be...
to ask if the client usually goes to bed and wakes up about the same time each day
The wife of a pt with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. You would recognize that the pt is likely showing the effects of:
tolerance
You are caring for a pt who has had a percutaneous tracheostomy (PCT) following a car accident and has been prescribed oxygen. What delivery device is most appropriate for this pt?
tracheostomy collar
You are suctioning a pt through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa
Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of...
trauma.
T/F. osteomyelitis can become chronic and affect pts QOL.
true
The FLACC scale is used for infants and children that are....
unable to validate the presence of or quantify pain severity
The anesthesiologist/pain management team should be notified immediately if the client exhibits what while being treated with epidural analgesia?
unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache.
The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:
use caution when driving an automobile.
Wick catheter
used to monitor compartment syndrome
An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client?
using a night light in the bathroom
Nurse planning care for older pt who's at risk of developing pressure ulcers. Which intervention will help to maintain integrity of pt's skin?
using a transfer device to lift the pt up in bed will prevent dragging pt's skin across the linens which can cause abrasions.
What does reducing a fracture mean?
when bone is placed back in alignment
The perception phase occurs...
when the pain threshold is reached.
A PCA pump is programmed...
with a lockout period that limits the chance of pts overmedicating themselves.
The PAINAD scale is specific to the needs of clients...
with dementia.
Chronic pain features the absence of autonomic nervous system responses and manifests...
with depression and irritability
Biot's respirations can be seen..
with meningitis or severe brain damage
Though their neurologic system is indeed developing, children feel pain acutely, and it is inappropriate to...
withhold analgesics until they are a "last resort."
Postop surgical wound infections normally happen
within 30 days after surgery
For pts with COPD, a level of 88%-92% may be considered...
within normal limits and there is no further action for you to take
if an implant has been used, deep postop infection may occur...
within the year
When suctioning through a tracheostomy tube, suctioning while advancing the tube...
would damage the tracheal mucosa and remove excessive amounts of oxygen
Adventitious breath sounds are...
abnormal lung sounds
Pts will describe somatic pain as _____ when asked if they can point to the location of their pain, they are often able to specifically pinpoint where it hurts.
aching or throbbing
Pts tend to describe visceral pain as....
aching, throbbing, cramping, pressure, deep, or radiating.
When the male pt on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, you should:
actively solicit information about the pt's pain level.
Wheezing is caused by...
air passing through constricted passages caused by swelling or secretions
Using a sedation scale, 1 indicates that the client is...
alert and awake.
How does a Bronchoscopy aid in diagnosing respiratory disorders?
allows the visualization of the airways directly.
What is hyperventilation?
an increased rate and depth of ventilation, above the body's normal metabolic requirements
What is croup?
an infection of the airways, most commonly viral in origin
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:
anticipate sleeping overnight at a health care center.
Some cultures see pain tolerance as a virtue, and men...
are expected to tolerate pain more stoically than women do
A client who has a decreased level of consciousness and an inability to swallow is at risk for....
aspiration
Apgar score is done at birth to...
assess how well the baby tolerated the birthing process.
You expect to document wheezing in the lungs of a pt with... asthma, which would be more pronounced when the client has a respiratory infection.
asthma, which could be more pronounced when pt has a respiratory infection
A 57 yr old pt is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the pt has been unwilling to mobilize despite your education on the benefits of early mobilization following surgery. You would recognize that the pt's prolonged immobility creates a risk for:
atelectasis
Caring for pt that had lacerated spleen and was on bedrest for several days. Nurse auscultates decreased breath sounds in the lower lobes of both lungs. She should realize that this is most likely an indication of...
atelectasis
Pneumonia can lead to...
atelectasis
Caring for pneumonia pt with prescription of O2 therapy at 5L/min via nasal cannula. What action should nurse take?
attach humidified to base of flow meter
Presence of pleural rub can be assessed through...
auscultation
Some fractures may cause disruption of the blood supply with death of tissue due to insufficient blood supply leading to...
avascular necrosis
If patient has risk factos for sleep apnea and you obs a pattern of sleep apnea, then next step should be to...
awaken the client, obtain and record vital signs, and notify the health care provider of the sleep pattern and vital sign results.
Referred pain can originate in one part of the body but...
be perceived in an area distant from its point of origin.
Nasal breathing allows the air to...
be warmed, filtered, and humidified
A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:
biofeedback
While experiencing phantom pain, the client perceives that the amputated limb still exists and feels ___,___, and ___ in tissues that have been surgically removed.
burning, itching, and deep pain
Clinical indication of Cheyne-strokes respiration
can result for severe CHF, drug overdose, increased intracranial pressure, or renal failure. - May be noted in elderly person during sleep not related to disease process
Absent breath sounds are...
characteristic of pneumonia
Helping older pt ambulate in hallway for first time since admission. Pt has brought standard walker from home and to ensure pt safety, which action should nurse take?
check that pt lifts walker and places it down in front of her.
The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?
cheese and crackers
Caring for pt with chronic respiratory insufficiency, which should expect as result of long-term inadequte oxygenation?
clubbing of fingers
Atelectasis is the...
collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation.
What does atelectasis refer to?
collapsed alveoli
Atelectasis is..
common after surgery or with obstruction or compression of the airways or lungs
Why is a careful neurovascular assessment important with an orthopedic injury?
compartment syndrome
open fracure is also called
compound fracture
The physician has ordered a patient controlled analgesia (PCA) pump for a pt. Which assessment finding would cause you to question the order?
confused to time and place
You are informed while receiving a nursing report that the pt has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
confusion
A pt has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. What do you think the pt is suffering from?
congestive heart failure
Hydromorphone is an opioid agent which is often ____ in older adults.
constipating
Pursed-lip breathing is a form of...
controlled ventilation that is effective for clients with COPD.
Transduction is the phase of pain referring to the...
conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord.
While using oxygen pt should wear....
cotton clothing and use cotton bedding and blankets
You auscultate a pt with soft, high-pitched popping breath sounds on inspiration. You documents the breath sounds heard as:
crackles
While suctioning a tracheostomy tube, the occlusion of the Y-port on suctioning tubing is what...
creates the suction
Common young children, what is a condition that obstructs upper airways by swelling the throat tissues?
croup
Persistent pain is...
cyclical,irreversible, and generally persists longer than 3 to 6 months.
phantom pain is a type of neuropathic pain that is often experienced....
days, weeks, or even months after the source of the pain has been treated and resolved.
A nursing instructor is describing the difference between sleep and rest. Which characteristic would the instructor identify as distinguishing sleep from rest?
decrease in awareness of environment
The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?
decreased REM sleep
A tracheostomy collar...
delivers oxygen near an artificial opening in the neck
An oxygen hood is a...
delivery device for infants that can deliver oxygen concentrations up to 80-90%
What effect does alcohol use have on the respiratory system?
depresses the central respiratory center
Skin tests are used to...
detect allergies
How are chest x-rays used to aid in respiratory disorder diagnosis?
detect pathologic lung changes
caring for pt requesting pain meds, what to do first?
determine location of pain
Visceral pain is often...
diffuse and difficult for pts to pinpoint.
What is visceral pain is associated with?
disease or injury
You is caring for a pt who has been prescribed humidified oxygen at 6 L/min. Which type of liquid will the nurse gather to set up the humidifier?
distilled water
Offering the client a book or music is using a technique of ____ to help the client not focus on the discomfort.
distraction
Why is it important to ask pt's about what medications they are taking?
drug-drug interactions
Asking how long the pain has existed reflects...
duration
For pts with exacerbated COPD, breathing into a paper bag would...
elevate the level of carbon dioxide and would be dangerous for this pt
When ___________ are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.
endogenous opioids
Coughing and deep breathing promote...
expectoration
Using an incentive spirometer promotes...
expectoration
A client having a myocardial infarction with chest pain is...
experiencing referred pain.
You are implementing an order for oxygen for a pt with facial burns. Which delivery device will the you gather?
face tent
Ramelteon is intended to...
facilitate sleep onset, not for sleep maintenance.
Acute pain responds...
favorably when pain medication is administered
You are conducting a respiratory assessment on a 71 year old pt who has been recently admitted. Which assessment finding should you interpret as abnormal?
fine crackles to the bases of the lungs bilaterally
During O2administration to pt, which pieces of equipment would enable you to regulate the amount of O2 delivered?
flow meter
Using a sedation scale, 3 is used to denote that the client is...
frequently drowsy, arousable but drifts off to sleep during a conversation.
Manifestations of a stage 4 pressure ulcer can include...
full-thickness skin loss with exposed or palpable bone or muscle.
Manifestations of a stage 3 pressure ulcer can include...
full-thickness skin loss with necrotic subcutaneous tissue.
The nurse is providing education to a group at a local community center on how to improve sleep quality. The nurse associates each intervention suggested with an example of how it can improve sleep. The nurse suggests that the clients.....
get up after 30 minutes of sleeplessness because it helps the mind to associate the bedroom with sleep
An older pt is visibly pale with a respiratory rate of 30bpm. Upon questioning, the pt states to you, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the pt's oxygen saturation using pulse oximetry, yielding a reading of 90%. You should interpret this oxygen saturation reading in light of the client's:
hb level
Why is light therapy beneficial for pts who travel and suffer from jet lag?
helps ease the transition to a new schedule or time zone.
How does keeping the bed no higher than 30 degrees help maintain skin integrity?
helps to minimize shearing forces
You're preparing to provide hygiene care to a pt with hypoxia. Into what position will you place the pt?
high Fowlers
Acute pain is associated with sympathetic nervous system responses such as....
hypertension, tachycardia, restlessness, and anxiety
cause excessive sleepiness and a lack of slow-wave sleep.
hypothyroidism
Increasing fluid intake to 1500-2500mL/d will help thinning of pulmonary secretions which....
improves the pt's ability to cough and remove the secretions.
The changes to the sleep cycle that usually occur in the older adult are:
increase in stage I and a decrease in deep sleep.
When pt experiencing hypoxia, a respiratory rate of 33 bpm indicates tachypnea r/t...
increased WOB
Pollutants cause...
increased mucus production and contribute to bronchitis and asthma
Acute pain consistently...
increases at night and during wound care, ambulation, coughing, and deep breathing.
How does vibration after, or instead of, percussion, loosen secretions and trigger coughing for a pt with a respiratory infection?
increases velocity and turbulance of air pt exhales
Air trapping
increasing difficulty in getting breath out
osteomyelitis
infection of the bone that results in inflammation, necrosis, and formation of new bone
A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?
insomnia
Abnormal chest structures would be assessed when...
inspecting the chest and thoracic region
Alcohol and diphenhydramine should not be administered with a sedative hypnotic drug, as this can....
intensify the medication.
Asking the client to rate pain on a 1-10 scale reflects...
intensity
deep postop surgical would infection description
involving tissue beneath the deep fascia
Referred pain...
is not experienced in the exact site where an organ is located.
Pts with emphysema are most comfortable in high Fowler's position because...
it aids in the use of the accessory muscles to promote respirations
How does vibration help a pt with respiratory infection?
it loosens secretions and triggers coughing.
when splinting a fractured limb...
joints distal and proximal to the suspected fracture site must be supported and immobilized
Sleep deprivation is the most appropriate nursing diagnosis for a pt with the symptoms of restless legs syndrome because...
keep the person awake and prevent continuous sleep.
Assessing pt with leg wound, nurse notes full thickness wound with jagged edges and muscle tissue visible. How to document the type of wound?
laceration
pt experiencing sleep disturbances and wnts to lower caffeine intake. which beverage should nurse recommend?
lemon-lime soda bc has no caffeine
Sleep restriction is the concept of...
limiting time in bed so that sleep does not become fragmented.
The nurse is discussing sleep interventions with a client. What statement made by the client indicates an understanding of sleep restriction?
limiting time in bed to actual sleep time
Increasing fluid intake to 1500-2500mL/d promotes....
liquefaction and thinning of pulmonary secretions
Visceral pain is poorly...
localized and originates in body organs in the thorax, cranium, and abdomen.
Pain related to appendicitis, a stab wound, or strep throat is more likely to be....
localized and sharp.
Ramelteon may be used....
long-term and activates receptors for melatonin.
Nebulizer therapy helps to...
loosen respiratory secretions
For pts with exacerbated COPD, administering oxygen at levels too high...
may diminish the client's stimulus to breathe, because a higher CO2 level is tolerated
If while performing diaphragmatic breathing the pt takes less than 2min long breaks it may...
may not be sufficient and may lead to sub-optimal oxygenation
A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?
modulation
Ataxic breathing is
more extreme expression of Biot's respirations indicating repiratory compromise
Chronic pain requires....
more frequent and higher doses of pain medication to elicit a positive response due to the threshold people build to the efficacy over time.
Which leg should move first when pt is using cane?
move weak leg with cane first, then bring strong leg forward ahead of cane and weak leg.
Somatic pain develops from injury to structures such as...
muscles, tendons, and joints.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
nasal cannula
Pt with COPD requires low flow O2. How will the O2 be administered?
nasal cannula
assessing pt with pressure ulcer, nurse should recognize which finding as manifestation of stage 3 pressure ulcer?
necrotic subcutaneous tissue
The CRIES scale is appropriate for...
neonates
A pt with an amputated arm tells you that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the pt experiencing?
neuropathic pain
Identify the Priority Assessment(s) after the cast is applied.
neurovascular status or name the 5 P's: Pulselessness, Paresthesia, Pain, Pallor, Paralysis
Oxygen is flammable; therefore...
no one should smoke nearby when it is in use. There should be no open flames in the area, either.
Chronic pain tends to be...
nonspecific and generalized
Vesicular, bronchial, and bronchovesicular breath sounds are...
normal breath sounds
To perform percussion...
nurse strikes skin over congested lung fields to loosen secretions.
The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is:
observe the client's hours of sleep and review the client's sleep diary.
Compartment syndrome
occurs when swelling happens around injury and is so severe that circulation is impared distal to the injury
Caring for 4 pts in orthopedic unit, which should nurse ID as eing at greater risk for skin breakdown?
older adult with hip fracture in buck's traction
high risk pts for osteomyelitis?
older adults, poorly nourished, obese, impaired immune systems, chronic illnesses, long-term corticosteroid therapy or immunosuppressive agents, IV drug users.
The FACES scale is used to assess pain in...
older children using a series of faces, ranging from a happy face to a crying face.
Asking when the pain began reflects...
onset
Stridor and crackles are...
other abnormal breath sounds caused by fluid, infection, or inflammation in lungs
When a client has a painful diagnosis and is nearing the end of life, what is the priority?
pain management
Manifestations of a stage 2 pressure ulcer can include...
partial-thickness skin loss and a superficial ulcer.
While examining a pt, you palpate the pt's chest and back. What would you expect to identify with this technique?
pattern of thoracic expansion
Asking if the client has had this pain before reflects...
patterns
Fluid-filled and consolidated portions of lungs can be assessed through...
percussion
Caring for teen with new cast for fractured tibia what is priority action
perform neurovascular assessment
Sleep apnea may result in....
periods of life-threatening apnea, hypoxia, and bradycardia.
A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?
phantom pain
The medulla and midbrain are part of the reticular activating system (RAS), which...
plays a part in the cyclic nature of sleep
Although crackles often indicate fluid in the alveoli, they can also be the result of....
positioning or decreased ventilation and will sometimes clear after a deep breath and cough
The Braden scale is used to...
predict pressure sore risk.
Monitoring oxygen saturation levels and promoting spirometry are...
preventative measures and don't immediately address the need for oxygen.
Performing ROM exercises at least 2-3 times a day....
prevents muscle atrophy and joint contractures
Raising head of the bed elevated 30-45 degrees of a pt with decreased LOC and difficulty swallowing will...
promote gastric emptying and reduce the risk of aspiration
Applying antiembolic stockings will help....
promote venous return and prevent edema.
Hospice nurse caring for terminal pt who takes morphine PO for pain. Pt reports had to increase morphine dose to obtain pain relief this week. Which scenario should nurse document to explain?
pt has developed a tolerance to the medication
Caring for postop pt, nurse should base pain management interventions primarily on which of the following methods of determining the intensity of the pts pain?
pt's self-report of pain severity
thick and odorous discharge
purulent
Asking the client to describe the pain establishes....
quality
Which factor necessitates the need for more sleep in the adolescent population?
rapid growth
REM is a deep stage of normal sleep. The body and brain go through several changes, including...
rapid movement of the eyes, fast and irregular breathing, increased heart rate (to near waking levels), changes in body temperature, increased blood pressure, and brain activity similar to that seen while awake.
Clients experiencing acute pain will indicate a ___ onset.
recent
What do health care providers need to do about their pt's cultural beliefs?
recognize the pt's cultural beliefs and not impose our own judgments.
Manifestations of a stage 1 pressure ulcer can include...
reddened intact skin and blood filled blisters.
Pain from the abdominal, pelvic, or back region may be ____ to areas far distant from the site of tissue damage.
referred
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?
referred pain
A pt describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?
referred pain
Psyllium helps promote...
regular bowel elimination
Stage 2 sleep is...
relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.
While using the biofeedback technique, we teach the pt to regulate their physiologic response and control pain through...
relaxation, imagery, or breathing exercises.
Clients experiencing chronic pain will indicate a ___ onset.
remote
Air pollution and high humidity are considered?
respiratory irritants
The medulla and midbrain are part of the...
reticular activating system (RAS)
Administer naloxone in order to....
reverse the effect of the opioid.
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?
reviewing and revising the pain management treatment plan
The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is:
reviewing the client's sleep diary for the past 2 weeks.
bloody discharge
sanguineous
Somatic pain is diffuse or...
scattered and originates in tendons, ligaments, bones, blood vessels, and nerves.
The most common side effects associated with opioid use are?
sedation, nausea, and constipation.
watery-red discharge
serosanguineous
yellowish drainage
serous
ataxic
significant disorganization with irregular and varying depths of respiration
