Care Exam 4 Practice Questions

b. Denial c. Bargaining d. Anger e. Depression

A charge nurse is reviewing Kubler-Ross' 5 stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply) a. Disequilibrium b. Denial c. Bargaining d. Anger e. Depression

c. "How do you take your prescribed blood pressure medications?"

A client with a history of hypertension presents to the clinic for an annual physical examination. The client reports a headache and the current blood pressure is 188/100 mm Hg. Which question by the nurse is priority based on the current data? a. "Has work been more stressful than usual lately?" b. "Have you taken any sinus or cold medications today?" c. "How do you take your prescribed blood pressure medications?" d. "How much processed food have you eaten over the past week?"

c. Stage 1 hypertension

A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

a. Changes in quantity and quality of sensory stimuli

A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? a. Changes in quantity and quality of sensory stimuli b. Changes in the amount or type of medication c. Excessive worry about a variety of things d. A mental condition that has previously gone undetected

d. Forgetfulness gradually progressing to disorientation

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? a. Decreased auditory and visual acuity b. Decreased display of emotions c. Personality traits that are opposite of original traits d. Forgetfulness gradually progressing to disorientation

c. Severe eye pain **Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? a. Multiple floaters b. Flashes of light in front of the eye c. Severe eye pain d. Double vision

b. Opacity visible behind pupil

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? a. Pupils nonreactive to light b. Opacity visible behind pupil c. White circle around the outside border of the iris d. Increased intraocular pressure

b. Stop the infusion

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Which of the following actions should the nurse perform FIRST? a. Elevate the extremity b. Stop the infusion c. Apply warm/cold compresses d. Remove the IV catheter

b. Open-angle glaucoma

A nurse is caring for a client who has diabetes and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a. Cataracts b. Open-angle glaucoma c. Macular degeneration d. Angle-closure glaucoma

d. Place both legs in dependent position when sleeping **will decrease swelling

A nurse is teaching a client who has a new diagnosis of severe PAD. Which of the following instructions should the nurse include? a. Wear tightly-fitted insulated socks with shoes when going outside b. Elevate both legs above the heart when resting c. Apply a heating pad to both legs for comfort d. Place both legs in dependent position when sleeping

b. Maintain a consistent daily routine for the patient's care

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past b. Maintain a consistent daily routine for the patient's care c. Reorient the patient to the date and time every 2 to 3 hours d. Provide the patient with current newspapers and magazines

c. "Would you like for me to sit down with you for a few minutes so you can talk about this?"

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse's first response is which of the following? a. "Don't be sad. People live with cancer every day." b. "Have you thought about how you are going to tell your family?" c. "Would you like for me to sit down with you for a few minutes so you can talk about this?" d. "I know another patient whose colon cancer was cured by surgery."

a. Improve her quality of life d. Focus on reducing the severity of disease symptoms

An 80-yr-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to do which of the following? (Select all that apply) a. Improve her quality of life b. Assess her coping ability with disease c. Have time to teach patient and family about disease d. Focus on reducing the severity of disease symptoms e. Provide care that the family is unwilling or unable to give

d. Asking the patient to describe previous stressful situations and how she managed to resolve them

An appropriate nursing intervention for a hospitalized patient who states she cannot cope with her illness is which of the following? a. Controlling the environment to prevent sensory overload and promote sleep b. Encouraging the patient's family to offer emotional support by frequent visiting c. Arranging for the patient to phone family and friends to maintain emotional bonds d. Asking the patient to describe previous stressful situations and how she managed to resolve them

c. Stress

A​ 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse​ assess? a. Family History b. Age c. Stress d. Sex

d. Syndrome characterized by cognitive dysfunction and loss of memory

Dementia is defined as which of the following? a. Syndrome that results only in memory loss b. Disease associated with abrupt changes in behavior c. Disease that is always due to reduced blood flow to the brain d. Syndrome characterized by cognitive dysfunction and loss of memory

c. Keep blinds open during the daytime hours

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Provide hourly orientation to time of day b. Move the patient to a quieter room at night c. Keep blinds open during the daytime hours d. Have the patient take a brief mid-morning nap

d. Prolonged grief

For the past 5 years, Tom as repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is she experiencing? a. Adaptive grief b. Disruptive grief c. Anticipatory grief d. Prolonged grief

c. Awareness of a full stomach **somatic complaint = highly aware of discomforts

In responding to a somatic complaint, the nurse would expect which of the following? a. Being aware train is coming because of hearing whistle b. Being aware of which foot is forward when walking c. Awareness of a full stomach d. Being aware of an unpleasant smell

d. lifestyle modifications are indicated for all persons with elevated BP

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that which of the following is true? a. all patients with elevated BP require medication b. obese persons must achieve a normal weight to lower BP c. it is not necessary to limit salt in the diet if taking a diuretic d. lifestyle modifications are indicated for all persons with elevated BP

c. Caregivers rarely take care of themselves and are at risk for poor health

Mr. P has been caring for his wife with end-stage Alzheimer's disease for the past three years. Mrs. P is admitted to your unit for pneumonia. Mr. P rarely takes a break to eat and sleeps in the hospital every night. You are concerned about his hospital routine why? a. It is not healthy for him to sleep in the hospital since he could get sick himself b. Mrs. P doesn't even recognize him anymore and doesn't need him to be there c. Caregivers rarely take care of themselves and are at risk for poor health d. It is disruptive to the unit to have Mr. P staying with his wife all the time

a. Normal grief

Mrs. Jones is experiencing difficulty sleeping and eating. It has been a month since her husband died, and she has come to the unit to thank the nurses for their excellent care. As the nurse that cared for Mr. Jones, you recognize that his wife is experiencing which of the following? a. Normal grief b. Complicated grief c. Disenfranchised grief d. Anticipatory grief

d. Cataracts **cataracts lead to vision being cloudy and blurred, which is how glasses might appear when they are dirty

The 65 yr old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? a. Macular degeneration b. Conjunctivitis c. Diabetic retinopathy d. Cataracts

c. Atherosclerosis **Atherosclerosis is the most common cause of PAD bc it blocks blood flow due to the collection of fatty plaques on the artery wall

The MOST common cause of peripheral arterial disease is which of the following? a. Diabetes b. Deep vein thrombosis c. Atherosclerosis d. Pregnancy

d. patient history and cognitive assessment

The clinical diagnosis of dementia is based on which of the following? a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment

c. Ensure no visitors or staff enter the room for a short period of time

The nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? a. Contact the hospital's spiritual services b. Ask what is making the client cry c. Ensure no visitors or staff enter the room for a short period of time d. Turn on the television for a distraction

b. Offer ideas for ways to distract or redirect the patient d. Educate the spouse about the availability of adult day care as a respite e. Ask the spouse what she knows and has considered about dementia care options

The spouse of a male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select all that apply) a. Suggest that a long-term care facility be considered b. Offer ideas for ways to distract or redirect the patient c. Suggest that the spouse consult with the physician for anti-anxiety drugs d. Educate the spouse about the availability of adult day care as a respite e. Ask the spouse what she knows and has considered about dementia care options

a. Previous experiences with grief and loss b. Religious affiliation and denomination c. Ethnic background and cultural practices

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply) a. Previous experiences with grief and loss b. Religious affiliation and denomination c. Ethnic background and cultural practices d. Current financial status e. Current medications

c. Cognitive changes secondary to cerebral ischemia

Vascular dementia is associated with which of the following? a. Transient ischemic attacks b. Bacterial or viral infection of neuronal tissue c. Cognitive changes secondary to cerebral ischemia d. Abrupt changes in cognitive function that are irreversible.

c. Choose a place without distracting stimuli

When administering a mental status examination to a patient with delirium, the nurse should do which of the following? a. Wait until the patient is well-rested b. Administer an anxiolytic medication c. Choose a place without distracting stimuli d. Reorient the patient during the examination

a. A client in pain

When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? a. A client in pain b. A homebound client c. A client on bed rest d. A client in isolation

b. Losing sense of time c. Difficulty performing familiar tasks d. Becoming lost in a usually familiar environment

When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply) a. Misplacing car keys b. Losing sense of time c. Difficulty performing familiar tasks d. Becoming lost in a usually familiar environment

b. Decrease in blood flow to the nerves of the feet

When teaching a patient about rest pain with PAD, what should the nurse explain as the cause of the pain? a. Vasospasm of cutaneous arteries in the feet b. Decrease in blood flow to the nerves of the feet c. Increase in retrograde venous perfusion to the lower legs d. Constriction in blood flow to leg muscles during exercise

d. "Tell me what you mean when you say you can't go on any longer."

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? a. "Are you thinking of suicide?" b. "You've been doing a good job raising your children. You can do it!" c. "Is there someone who can help you during the evenings and weekends?" d. "Tell me what you mean when you say you can't go on any longer."

b. Tobacco use

A 50-year-old woman who weighs 95 kg has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. Which is the most important risk factor for peripheral artery disease (PAD) to address in the nursing plan of care? a. Salt intake b. Tobacco use c. Excess weight d. Sedentary lifestyle

c. "What did you have for breakfast?" **This question tests the patient's recent memory, which is decreased early in Alzheimer's disease (AD) or dementia

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do you have any feelings of sadness?" c. "What did you have for breakfast?" d. "How positive is your self-image?"

c. Loss of recent and long-term memory

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find which of the following? a. Excessive nighttime sleepiness b. Difficulty eating and swallowing c. Loss of recent and long-term memory d. Fluctuating ability to perform simple tasks

a. The patient was oriented and alert when admitted **delirium has a sudden onset

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted b. The patient's speech is fragmented and incoherent c. The patient is oriented to person but disoriented to place and time d. The patient has a history of increasing confusion over several years.

d. Take prescribed antihypertensive medication.

A client diagnosed with chronic hypertension earlier in the year arrives to the clinic with a blood pressure of 192/98 mm Hg. Which is the priority teaching the nurse provides for this client based on the current data? a. Exercising 30 minutes a day. b. Limit sodium and potassium intake. c. Daily weights on the same scale. d. Take prescribed antihypertensive medication.

b. Caregiver role strain

A client expresses to the nurse that she constantly feels irritated and loses her temper. During the course of the interview, the nurse finds that the client takes care of her mother who was confined to bed following a stroke. The client struggles to balance caring for her family and her mother. Which nursing diagnosis would the nurse most likely identify for this client? a. Compromised family adjustment b. Caregiver role strain c. Ineffective coping d. Anxiety

d. Sensory reception **Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli

A client has expressed great relief at the improvement in her hearing after irrigation of her ear canal yielded a large amount of impacted cerumen (wax). This client was experiencing a sensory alteration related to which of the following? a. Sensory reaction b. Sensory perception c. Sensory transmission d. Sensory reception

c. Bargaining

A client has just been informed of a diagnosis of terminal cancer. The client states, "God has to have mercy on me because my children need me. He knows I'll change if he gets me through this." The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? a. Denial b. Anger c. Bargaining d. Depression

a. Cardiovascular disease

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? a. Cardiovascular disease b. Frequent urinary tract infections c. A history of migraine headaches d. Frequent upper respiratory infections

a. Dilated pupils b. Diaphoretic c. Tachycardia

A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress. What did the nurse assess to make this determination? (Select all that apply) a. Dilated pupils b. Diaphoretic c. Tachycardia d. Flaccid muscle tone e. Excessive oral secretions

c. "I am still wishing I had gotten help to him sooner."

A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt? a. "I know that my husband had a good life." b. "It seems I miss my son more as time goes on." c. "I am still wishing I had gotten help to him sooner." d. "The Christmas season is always a sad time for me."

b. Scatter rugs are present in the kitchen

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? a. Electrical cords are placed along the walls b. Scatter rugs are present in the kitchen c. Handrails are present in the bathroom d. Uses a microwave for cooking

a. "Dry between your toes after​ showering."​ b. "Apply moisturizing cream to feet and legs​ daily."

A home health nurse is caring for a client with peripheral vascular disease​ (PVD). When teaching the client regarding foot and leg​ care, which statement should the nurse​ include? (Select all that​ apply)​ a. "Dry between your toes after​ showering."​ b. "Apply moisturizing cream to feet and legs​ daily." c. Avoid using powder on your​ feet."​ d. "When swimming, ensure the water is​ cool, not​ warm."

b. Install locks at the tops of exterior doors **Alzheimer's pts are at an increased risk of wandering and getting lost

A home health nurse is providing teaching for the family of a client who has moderate Alzheimer's disease. The family plans to care for the client in the home. Which of the following recommendations should the nurse include in the teaching? a. Place nonskid rugs over smooth floors b. Install locks at the tops of exterior doors c. Provide clothing that has zippers instead of buttons d. Encourage the client to take frequent naps during the day

c. Ask if the patient would like to talk about his feelings

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? a. Give the patient a hug and tell him that his life still has meaning b. Arrange for a spiritual adviser to visit the patient c. Ask if the patient would like to talk about his feelings d. Call in a close friend or relative to talk to the patient

c. Assess for factors that might be causing discomfort **Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to do which of the following? a. Reorient the patient to time, place, and person b. Administer the PRN dose of lorazepam (Ativan) c. Assess for factors that might be causing discomfort d. Have a nursing assistant stay with the patient to ensure safety

a. Maintain patient safety

A major goal of treatment for the patient with Alzheimer's disease is to do which of the following? a. Maintain patient safety b. Maintain or increase body weight c. Return to a higher level of self-care d. Enhance functional ability over time

a. Consult the medication reference book available on the unit

A newly licensed nurse is preparing to administer a medication to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? a. Consult the medication reference book available on the unit b. Ask a more experienced nurse for information on the medication c. Call the client's provider and verify the prescription d. Ask the client if she takes this medication at home

b. Denial

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again". The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger

d. "I am your nurse. Let's walk together to your room"

A nurse in a long-term care facility is caring for a client who has Alzheimer's and tries to wander out of the building. The client states, "I have to get home". Which of the following statements should the nurse make? a. "You have forgotten that this is your home" b. "You cannot go outside without a staff member" c. "Why would you want to leave? Aren't you happy here?" d. "I am your nurse. Let's walk together to your room"

a. Denial

A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the exam room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions? a. Denial b. Displacement c. Projection d. Undoing

c. "I just can't believe that this dialysis is going to ruin my whole life"

A nurse is a caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? a. "I know that I will get a kidney transplant. I am a good candidate" b. "I can now eat whatever I want. The dialysis will remove it from my system" c. "I just can't believe that this dialysis is going to ruin my whole life" d. "I know that kidney disease runs in my family, but I can prevent it"

b. Edema

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? a. Dependent rubor b. Edema c. Hair loss d. Thick, deformed toenails

b. Viral infection

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a. Hypotension b. Viral infection c. Increased energy d. Increased cognitive awareness

a. Cataracts

A nurse is assessing a client who reports an acute visual disturbance that he describes as decreased color perception and blurry vision. The nurse should notify the provider that this client might have which of the following disorders? a. Cataracts b. Angle-closure glaucoma c. Retinal detachment d. Macular degeneration

d. "I feel so empty without my wife that it's hard to get up every morning"

A nurse is assessing a client whose partner died 4 months ago. Which of the following indicates that the client is at risk of complicated grief? a. "I wish I had been more generous to my wife before she died" b. "I told my wife to go to the doctor, but she would not listen to me" c. "I think about my wife all the time when I go to outings with my family" d. "I feel so empty without my wife that it's hard to get up every morning"

d. Pallor on elevation of the limbs, and rubor when the limbs are dependent

A nurse is assessing a client with chronic PAD. Which of the following findings should the nurse expect? a. Edema around the ankles and feet b. Ulceration around the medial malleoli c. Scaling eczema of the lower legs d. Pallor on elevation of the limbs, and rubor when the limbs are dependent

b. Leg pain at rest

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect? a. Thin, pliable toe nails b. Leg pain at rest c. Hairy legs d. Flushed, warm legs

a. Leaves the child's room exactly as it was before the loss

A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is experiencing manifestations of prolonged grieving? a. Leaves the child's room exactly as it was before the loss b. Volunteers at a local children's hospital c. Talks about the child in the past tense d. Visits the child's grave every week after worship services

c. I will apply fresh linens and place a clean gown on the body d. I will remove all equipment from the bedside e. I will dim the lights in the room

A nurse is assisting a newly licensed nurse with postmortem care to a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of this procedure? (Select all that apply) a. I will remove the dentures from the body b. I will make sure the body is lying completely flat c. I will apply fresh linens and place a clean gown on the body d. I will remove all equipment from the bedside e. I will dim the lights in the room

b. The client's husband died seven months ago **One of the defining factors of maladaptive grieving if grief that last 6 months or longer after the loss

A nurse is caring for a 48 year old client who is grieving. The client reports that her husband died seven months ago, that she has lost 30 lb, and that she has difficulty sleeping. Which of the following item of data indicate that the client is experiencing maladaptive grieving? a. The client is 48 years old b. The client's husband died seven months ago c. The client has lost 30 lb d. The client has difficulty sleeping

b. Place the client in a room near the nurses' station

A nurse is caring for a client who has Alzheimer's and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a. Keep the call light near the client b. Place the client in a room near the nurses' station c. Encourage the client to ask for assistance d. Remind the client to walk with someone for assistance

a. Vertigo **monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? a. Vertigo b. Uremia c. Blurred vision d. Dyspnea

b. Allow the client to provide input in the treatment plan c. Assist the client with time management, and address the client's priorities e. Encourage the client in the expression of feelings and concerns

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (Select all that apply) a. Suggest coping skills for the client to utilize in this situation b. Allow the client to provide input in the treatment plan c. Assist the client with time management, and address the client's priorities d. Provide extensive instructions on the client's treatment regimen e. Encourage the client in the expression of feelings and concerns

d. Decreased muscle tone

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse about anticipated findings at this time. which of the following findings should the nurse include in the discussion? a. Regular breathing patterns b. Warm extremities c. Increased urine output d. Decreased muscle tone

c. "Let's set up a meeting time with the doctor to discuss your options for home care"

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? a. "Social services can contact various community resources that will be helpful" b. "I will review the care plan to make the necessary changes" c. "Let's set up a meeting time with the doctor to discuss your options for home care" d. "I will make a list of things we need to do before discharge"

b. Rapid fluctuation in level of consciousness

A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? a. Progressive deterioration of cognitive function b. Rapid fluctuation in level of consciousness c. Loss of language ability d. Absence of contributing factors to pinpoint the cause of delirium

c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication"

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process? a. "The doctor has been so good to me. I know he has tried everything he can. It's just my time" b. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer" c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication" d. Even though I am not hurting now, I don't feel like I have the energy to get out of bed

b. Apply the stockings in the morning upon wakening and before getting out of bed

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? a. Elevate the client's legs for 10 minutes, 2-3 times per day while wearing stockings b. Apply the stockings in the morning upon wakening and before getting out of bed c. Roll the stockings down to the knees to relieve discomfort on the legs d. Remove the stockings while out of bed for 1 hr, 4 times a day to allow the legs to rest

c. "Tell me what you like to cook for dinner."

A nurse is caring for a client who has dementia due toAlzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse Is appropriate? a. "This is where you live now." b. "This is a safer place for you to live." c. "Tell me what you like to cook for dinner." d. "Your family said there is no one to care for you at home."

b. Maintain a low-stimulation environment

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? a. Assign the client several tasks at the same time b. Maintain a low-stimulation environment c. Advise family to visit frequently as a group d. Encourage the client to make choices regarding care.

a. Assist the client to the correct room

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? a. Assist the client to the correct room b. Place the client in restraints c. Reorient the client to time and place d. Move the client to a room at the end of the hall

b. Dependent rubor

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? a. Intermittent claudication b. Dependent rubor c. Rest pain d. Foot ulcers

c. Speak directly to the client in a normal, clear voice

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? a. Speak loudly and into the client's good ear b. Use sign language when communicating with the client c. Speak directly to the client in a normal, clear voice d. Sit by the client's side and speak very slowly

c. Provide a private room, and limit stimulation.

A nurse is caring for a client who has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment. b. Put the client in a room with a client who is hearing impaired. c. Provide a private room, and limit stimulation. d. Talk loudly to the client, and encourage ambulation.

c. Bargaining

A nurse is caring for a client who has stage IV lung cancer and is 3 days postop following a wedge resection. the client states, i told myself that i would go through with the surgery if i quit smoking, if i could just live long enough to attend my daughters wedding.based on Kubler-Ross' model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance

c. The client's sense of loss can be lessened through retaining control of certain areas of her life

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. which of the following rationales for self-care should the nurse communicate to the family? a. Allowing the client to function independently will strengthen her muscles and promote healing b. The client needs to be given privacy at times for self- reflecting and organizing her life. c. The client's sense of loss can be lessened through retaining control of certain areas of her life d. Performing ADLs is required prior to discharge from an acute care facility

b. Edema at the infusion site **Edema d/t fluid entering subq tissue is an indication of infiltration; redness and warmth = phlebitis or infection; oozing = nonintact IV system

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? a. Redness at the infusion site b. Edema at the infusion site c. Warmth at the infusion site d. Oozing of blood at the infusion site

a. Offer to make arrangements for the Sacrament of the Sick

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate? a. Offer to make arrangements for the Sacrament of the Sick b. Prepare to stay with the client's body until family arrives c. Arrange for a member of the client's family to bathe the body after death d. Post a sign on the client's door stating "No talking"

a. "You sound angry. Anger is a normal feeling associated with loss"

A nurse is caring for a client who lost a guardian to cancer last month. The client states, "I'd still have my guardian if the doctor would have made a diagnosis sooner". Which of the following responses should the nurse make? a. "You sound angry. Anger is a normal feeling associated with loss" b. "I think you would feel better if you talked about your feelings with a support group" c. "I understand just how you feel. I felt the same when my guardian died" d. "Do other members of your family also feel this way?"

d. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not acceptable treatment option. Which of the following responses should the nurse make? a. "I believe in this case you should really make an exception and accept the blood transfusion." b. " I know your family would approve of your decision to have a blood transfusion." c. "Why does your religion mandate that you cannot receive any blood transfusion?" d. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"

b. The client has kept his partner's closet untouched since her death

A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? a. The client joined a bowling league 2 months ago b. The client has kept his partner's closet untouched since her death c. The client exercises at a local health facility 3 days each week d. The client meets his daughter for dinner every week

b. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."

A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse? a. "It takes time to get over the loss of a loved one." b. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." c. "Why don't you try something to take your mind off your troubles, like watching a funny movie." d. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

c. Keep familiar personal items at the bedside

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? a. Turn the television on at all times b. Hang abstract pictures on the walls c. Keep familiar personal items at the bedside d. Encourage bright glaring lighting in the room

b. A client attempts to climb out of bed and repeatedly states she must get home

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? a. A client wants to know the current time when there is a clock on the wall b. A client attempts to climb out of bed and repeatedly states she must get home c. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F) d. A client refuses to get out of bed and has no motivation to attend to daily hygiene

b. Genetic predisposition c. Hypertension d. Age e. Diabetes mellitus

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply) a. Sex b. Genetic predisposition c. Hypertension d. Age e. Diabetes mellitus

b. open-angle glaucoma

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following disease? a. cataracts b. open-angle glaucoma c. macular degeneration d. angle-closure glaucoma

a. "This must be a difficult time for you"

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life". Which of the following responses is appropriate? a. "This must be a difficult time for you" b. "Now she is no longer suffering" c. "I felt the exact same when my husband died" d. "You will feel better eventually"

c. The same religious beliefs can influence individuals differently

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these patients? a. Members of the same religion share similar feelings about their religion b. A shared religious background generates mutual regard for one another c. The same religious beliefs can influence individuals differently d. The nurse and client should discuss the differences and commonalities in their beliefs

b. Therapeutic communication builds a relationship that will allow expression of mutual concerns

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client? a. Therapeutic communication identifies and analyzes the client's problem b. Therapeutic communication builds a relationship that will allow expression of mutual concerns c. Therapeutic communication provides a basis for the client's relationship with the provider d. Therapeutic communication ensures the client will remain cooperative with his care in the facility

b. "Are you having trouble carrying on with your normal activities?"

A nurse is conducting a grief and loss assessment interview and understands that the current loss, the history of previous losses, and lifestyle are all a part of this assessment. What question will the nurse ask the client to assess the current loss? a. "Do you drink on a regular basis?" b. "Are you having trouble carrying on with your normal activities?" c. "What types of coping mechanisms have you employed to work through your grief? d. "Do you have an active support system?"

a. Client's level of comfort and ability to participate in the interview

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? a. Client's level of comfort and ability to participate in the interview b. Previous illnesses and surgeries c. Event's surrounding the client's recent illness d. Sociocultural history

a. "Would you like me to contact the chaplain to come speak with you?" d. "You know, it is quite normal to feel anger toward your husband at this time." e. "Tell me more about how you are feeling."

A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) a. "Would you like me to contact the chaplain to come speak with you?" b. "You will feel better soon. You have been expecting this for a while now." c. "Let's talk about your children and how they are going to react." d. "You know, it is quite normal to feel anger toward your husband at this time." e. "Tell me more about how you are feeling."

c. "I will begin upon the client's admission to the facility"

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? a. "I will begin 48 hrs before the client's discharge" b. "I will begin once the client's discharge order is written" c. "I will begin upon the client's admission to the facility" d. "I will begin once the client's insurance company approves discharge coverage"

b. Decreased immune system c. Increased blood pressure e. Unhappiness

A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply) a. Chronic pain b. Decreased immune system c. Increased blood pressure d. Panic attacks e. Unhappiness

a. "I may experience feelings of resentment" b. "I will probably withdraw from others" c. "I can expect to experience changes in sleep"

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply) a. "I may experience feelings of resentment" b. "I will probably withdraw from others" c. "I can expect to experience changes in sleep" d. "It is possible that I will experience suicidal thoughts" e. "It is expected that I will have a loss of self-esteem"

b. "I will ask the client if they want to schedule some times to pray during the day"

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements from the nurse indicates culturally responsive care to the client? a. "I will make sure the menu includes kosher options" b. "I will ask the client if they want to schedule some times to pray during the day" c. "I will avoid discussing care when the client's family is around" d. "I will make sure daily communion is available for this client"

a. Remove the sleeve of the gown from the arm without the IV line

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without the IV line b. Slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

c. The partner has lost 20 lbs in the past 2 months

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? a. The partner has placed locks at the top of the doors leading to the outside b. The partner has hired a house cleaner c. The partner has lost 20 lbs in the past 2 months d. The partner redirects the client when the client is frustrated

a. Remove floor rugs c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor

A nurse is making a home visit to a client who has Alzheimer's. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply) a. Remove floor rugs b. Have door locks that can be easily opened c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor

a. Demonstrate hearing aid battery replacement. b. Review method to check volume on hearing aid. d. Discuss the importance of having wax buildup in the ear canal removed.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." After determining that the patient's hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply) a. Demonstrate hearing aid battery replacement. b. Review method to check volume on hearing aid. c. Demonstrate how to wash the ear-mold and microphone with hot water. d. Discuss the importance of having wax buildup in the ear canal removed. e. Recommend a chemical cleaner to remove difficult buildup.

d. "What is your source of strength and hope?"

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? a. "When did you start to believe in your faith?" b. "How often do you perform religious rituals?" c. "Which church do you regularly attend?" d. "What is your source of strength and hope?"

b. Family report of personality changes c. Hallucinations e. Restlessness

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply) a. History of gradual memory loss b. Family report of personality changes c. Hallucinations d. Unaltered level of consciouness e. Restlessness

c. "How can I and the other nurses help you maintain your spiritual practices?"

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question to assess for spiritual needs? a. "Can you describe your usual spiritual practices and how you maintain them daily?" b. "Are your spiritual beliefs causing you any concern?" c. "How can I and the other nurses help you maintain your spiritual practices?" d. "How do your religious beliefs help you to feel at peace?"

a. Excessive stressors cause the client to experience distress

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? a. Excessive stressors cause the client to experience distress b. The body's initial adaptive response to stress is denial c. Absence of stressors results in homeostasis d. Negative, rather than positive, stressors produce a biological response

c. Give a written summary of the client's nursing plan of care to the long-term care facility

A nurse is preparing to transfer an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse take? a. Discuss the client's long-term recovery goals with him b. Discuss the client's nursing care needs with the provider c. Give a written summary of the client's nursing plan of care to the long-term care facility d. Review the client's nursing care plan with his family members

d. Offer the mother private time with the newborn

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first? a. Assist the client with transferring to the gynecology unit b. Administer Alprazolam 0.5 mg PO c. Contact the health care facility's clergy d. Offer the mother private time with the newborn

b. Adjust the thermostat so that the environment is warm **The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? a. Apply a heating pad on a low setting to help relieve leg pain b. Adjust the thermostat so that the environment is warm c. Wear antiembolic stockings during the day d. Rest with the legs above the heart

a. "Without treatment, glaucoma can cause blindness"

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? a. "Without treatment, glaucoma can cause blindness" b. "Double vision is a common symptom of glaucoma" c. "Glaucoma is caused by inadequate production of fluid within the eye" d. "Use of eye drops will improve vision over time"

b. Check the expiration dates on food

A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the​ teaching? a. Set up a schedule for changing the batteries in carbon monoxide detectors b. Check the expiration dates on food c. Recommend the client purchase smoke detectors with flashing lights d. Darken the rooms with shades

d. Limit choices offered to the client **Choices should be limited for the client to reduce confusion and frustration

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Place abstract pictures on the wall in the client's room b. Provide music for the client using headphones c. Reorient the client to reality frequently d. Limit choices offered to the client

d. "I take the batteries out of my hearing aids when I take them off at night."

A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions? a. "I use a damp cloth to clean the outside part of my hearing aids." b. "I clean the ear molds of my hearing aids with rubbing alcohol." c. "I keep the volume of my hearing aids turned up so I can hear better." d. "I take the batteries out of my hearing aids when I take them off at night."

b. Eating popcorn at the movie theater d. Consuming 36oz beer daily

A nurse is screening a client for hypertension. The nurse should identify that which of the following actions by the client increases the risk for hypertension? (Select all that apply) a. Drinking 8oz non-fat milk daily b. Eating popcorn at the movie theater c. Walking 1 mile daily at 12 min/mile pace d. Consuming 36oz beer daily e. Getting a massage 1x per week

b. Sudden confusion **Alzheimer's is gradual

A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that the group requires further teaching when a member identifies which of the following findings as a manifestation of Alzheimer's disease? a. Impaired judgment b. Sudden confusion c. Personality change d. Remote memory loss

a. Spirituality decreases feelings of depression

A nurse is teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include? a. Spirituality decreases feelings of depression b. Spirituality increases feelings of hopelessness c. Spirituality decreases quality of life d. Spirituality increases the desire to hasten death

a. "This medication will prevent me from developing a blood​ clot."​

A nurse is teaching a client about aspirin for peripheral vascular disease​ (PVD). Which client statement indicates that teaching has been​ successful?​ a. "This medication will prevent me from developing a blood​ clot."​ b. "This medication will thin out my blood so it flows​ easier."​ c. "This medication will open my arteries and increase blood flow to my​ legs."​ d. "This medication will help decrease the plaque in my​ arteries."

a. "Cognitive reframing will help me change my irrational thoughts to something positive"

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? a. "Cognitive reframing will help me change my irrational thoughts to something positive" b. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" c. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety" d. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety"

d. Driving can be dangerous due to the loss of peripheral vision **Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated; Eye drops will not improve vision but they can reduce intraocular pressure and prevent further vision loss

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma. Which of the following information should the nurse include in the teaching? a. Lost vision can improve with eye drops b. Administer eye drops as needed for vision loss c. Glasses will be necessary to correct accompanying presbyopia d. Driving can be dangerous due to the loss of peripheral vision

b. "Use elastic stockings"

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? a. "Apply ice packs to your legs" b. "Use elastic stockings" c. "Remain on bed rest" d. "Place your legs in a dependent position while in bed"

d. Feeling of fullness in the ear **A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is teaching the client about otitis media. Which of the following manifestations should the nurse include in the teaching? a. A high-pitched sound heard in the ear b. Intermittent rapid eye movement c. Itching on the external canal d. Feeling of fullness in the ear

b. Determine client understanding several times during the conversation d. Use lay terms if possible. e. Do not interrupt the interpreter and the family as they talk

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply) a. Talk to the interpreter about the family while the family is in the room b. Determine client understanding several times during the conversation c. Look at the interpreter when asking the family questions d. Use lay terms if possible. e. Do not interrupt the interpreter and the family as they talk

a. Interpersonal relationships b. Culture d. Religious beliefs e. Prior experience with loss

A nurse is working with a client who recently lost a guardian. The nurse recognizes that which of the following factors influences a client's grief and coping ability? (Select all that apply) a. Interpersonal relationships b. Culture c. Birth order d. Religious beliefs e. Prior experience with loss

d. Talk the client through tasks one step at a time

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? a. Rotate assignment of daily caregivers b. Provide an activity schedule that changes from day to day c. Limit time for the client to perform activities d. Talk the client through tasks one step at a time

b. Loss of central vision

A nurse performs an assessment of a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which of the following symptoms? a. Loss of peripheral vision b. Loss of central vision c. Cloudiness of the lens d. Sudden, severe pain

c. "Did either prayer or meditation prove helpful to you?"

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? a. "Do you feel the need to forgive your wife over your loss?" b. "What can I do to help you feel more at peace?" c. "Did either prayer or meditation prove helpful to you?" d. "Should we plan on having your family try to visit you more often in the hospital?"

a. venous ulcer **the wet wound and drainage indicates a venous ulcer

A patient has an ulcer on the medial malleolus. The ulcer is shallow with irregular edges. The wound base is red. Wound drainage is also present. What type of ulcer is this based on the scenario's description? a. venous ulcer b. arterial ulcer c. diabetic ulcer

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

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

b. Sit down and talk with the patient; have her discuss her feelings and listen attentively.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? a. Make a referral to a professional spiritual care adviser. b. Sit down and talk with the patient; have her discuss her feelings and listen attentively. c. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. d. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

b. Application of compression stockings c. Limit long periods of standing and sitting **The patient with peripheral VENOUS disease should elevate the lower extremities ABOVE heart level (this helps return blood to the heart and decrease swelling/pain), avoid crossing the legs (or the knee-flexed position) because this impedes blood flow, and limit long periods of standing and sitting (this limits blood return to the heart and increases swelling)

A patient has severe peripheral venous disease. What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease? (Select all that apply) a. Elevate the lower extremities below heart level frequently b. Application of compression stockings c. Limit long periods of standing and sitting d. Use the knee-flexed position while lying in bed

c. A diagnosis of AD is made only after other causes of dementia are ruled out

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that.... a. The most important risk factor for AD is a family history of the disorder b. New drugs have been shown to reverse AD dramatically in some patients c. A diagnosis of AD is made only after other causes of dementia are ruled out d. The presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

a. Denial

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Displacement

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

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? a. Minimize background noises and ensure that lighting is adequate to see the nurse's face b. Use written communication whenever possible in order to minimize Mr. Fields' frustration c. Use vocabulary and concepts that are as simple and unambiguous as possible d. Repeat each direction or question in different terms in order to maximize understanding

a. Lethargy b. Increased pulse rate d. Decreased urine output

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac​ output? (Select all that​ apply) a. Lethargy b. Increased pulse rate c. Capillary refill less than <3 seconds d. Decreased urine output e. Palpable pedal pulses

c. Face the patient when speaking; demonstrate ideas you wish to convey. e. Verify that the information that has been given has been clearly understood.

An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply) a. Talk to the patient at a distance so he or she may read your lips. b. Keep your arms at your side; speak directly into the patient's left ear. c. Face the patient when speaking; demonstrate ideas you wish to convey. d. Position the patient so that the light is on his or her face when speaking. e. Verify that the information that has been given has been clearly understood.

b. perception

Determination of whether an event is a stressor is based on a person's... a. tolerance b. perception c. adaptation d. stubbornness

b. A more bounding pulse **During this shock phase, the sympathetic nervous system is stimulated, resulting in increased myocardial contractility, which would be reflected in the client as a bounding pulse

The client has just received news of the death of a relative. Over the next few hours, what physiologic response should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event? a. Drop in blood pressure from 130/80 to 120/75 b. A more bounding pulse c. Slight increase in urine output d. Some decrease in oxygen saturation

b. Memory problems and mild confusion

The early stage of Alzheimer's disease is characterized by which of the following behaviors? a. No noticeable change in behavior b. Memory problems and mild confusion c. Increased time spent sleeping or in bed d. Incontinence, agitation, and wandering behavior

b. Development of beta-amyloid plaques in between neurons d. Creation of neurofibrillary tangles within the neuron

The exact cause of Alzheimer's disease is not fully understood. However, what two changes in the brain are found in a patient with this disease? (Select all that apply) a. Destruction of the myelin sheath on the neuron b. Development of beta-amyloid plaques in between neurons c. Destruction of dopaminergic neurons d. Creation of neurofibrillary tangles within the neuron

b. Use of warm incandescent lighting c. Use of yellow or amber lenses to decrease glare d. Use of adjustable blinds, sheer curtains, or draperies

The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply) a. Use of fluorescent lighting b. Use of warm incandescent lighting c. Use of yellow or amber lenses to decrease glare d. Use of adjustable blinds, sheer curtains, or draperies e. Indirect lighting to reduce glare

d. A 72-year-old female is unable to locate the address where she has lived for 10 years **An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease)

The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? a. A 65-year-old male does not recognize his family members and close friends b. A 59-year-old female misplaces her purse and jokes about having memory loss c. A 79-year-old male is incontinent and not able to perform hygiene independently d. A 72-year-old female is unable to locate the address where she has lived for 10 years

a. Sensorineural hearing loss that occurs with aging

The nurse has notes that the physician has a diagnosis of Presbycusis on the client's chart. The nurse plans care knowing the condition is which of the following? a. Sensorineural hearing loss that occurs with aging b. Conductive hearing loss that occurs with aging c. Tinnitus that occurs with aging d. Nystagmus that occurs with aging

b. 43-year-old with a BP of 190/102 who is complaining of chest pain **The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

b. Provide thickened fluids and moist foods in bite-size pieces

The nurse in the long-term care facility cares for a 70-year-old man with severe (late-stage) dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient? a. Turn on the television to provide a distraction during meals b. Provide thickened fluids and moist foods in bite-size pieces c. Limit fluid intake during scheduled meals to prevent aspiration d. Allow the patient to select favorite foods from the menu choices.

a. Lower extremity edema b. Cyanosis of lower legs **Manifestations of CVI include lower extremity edema that worsens with​ standing; itching, dull leg discomfort or pain that increases with​ standing; thin,​ shiny, atrophic​ skin; cyanosis and brown skin pigmentation of lower leg and​ foot; possible weeping​ dermatitis; thick, fibrous​ (hard) subcutaneous​ tissue; and recurrent ulcerations of medial or anterior ankles.

The nurse is assessing a client diagnosed with chronic vascular insufficiency​ (CVI). Which assessment finding should the nurse​ expect? (Select all that​ apply) a. Lower extremity edema b. Cyanosis of lower legs c. Soft subcutaneous tissue on affected areas on leg d. Excessive hair growth on the legs d. Pale skin on lower legs

b. Hypertension and diabetes mellitus **risk for increased IOP and diabetic retinopathy

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? a. Hypothyroidism and polycythemia b. Hypertension and diabetes mellitus c. Atrial fibrillation and atherosclerosis d. Vascular dementia and chronic fatigue

b. I may be able to dress more easily with zippers or pullover sweaters."

The nurse is conducting discharge teaching for a client with diminished tactile sensation. Which of the following statements by the client would indicate that teaching was ineffective? a. "I am at risk for injury from temperature extremes." b. I may be able to dress more easily with zippers or pullover sweaters." c. "A home care referral may help me achieve a maximum degree of independence." d. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

d. Assess the posterior tibial and pedal pulses **This client is describing symptoms of intermittent claudication. The nurse should assess the strength and equality of peripheral pulses to determine perfusion. Changes in skin color are important but not the priority

The nurse is evaluating a client who​ states, "I usually walk 30 minutes every​ morning, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop​ walking, though." Which action should the nurse do first​? a. Notify the healthcare provider b. Discuss benefits of daily exercise c. Ask the client about skin color changes d. Assess the posterior tibial and pedal pulses

c. "I'm going to let the occupational therapist assess my home to improve efficiency." e. "I'm going to attend a support group to learn more about multiple sclerosis."

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply) a. "I'm going to learn to drive a car, so I can be more independent." b. "My sister says she feels better when she goes shopping, so I'll go shopping." c. "I'm going to let the occupational therapist assess my home to improve efficiency." d. "I've always felt better when I go for a long walk. I'll do that when I get home." e. "I'm going to attend a support group to learn more about multiple sclerosis."

b. Clear simple directions

The nurse is helping a patient with Moderate Alzheimer's disease (Middle Stage) participate in a task. When selecting a task for the patient, the nurse would want to make sure the task has? a. Multiple steps b. Clear simple directions c. Critical thinking d. Usage of multiple tools

d. Delayed capillary refill in the lower extremities

The nurse is performing an assessment on a client with peripheral vascular disease​ (PVD). Which finding should the nurse​ expect? a. Wheezing upon auscultation of the lungs b. Decreased sensation of the upper extremities c. Dilated blood vessels in the eye d. Delayed capillary refill in the lower extremities

d. Rephrase the direction in different terms **Rephrasing an instruction in simple terms may enhance a confused client's understand. This is preferable to proceeding in spite of the client

The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond first? a. Reposition the client without the client's assistance b. Enlist the assistance of a colleague c. Ask the client if she is feeling confused d. Rephrase the direction in different terms

b. Use touch when appropriate c. Incorporate nonverbal communication d. Have music and imagery available during the day

The nurse is providing routine care for a patient with Severe Alzheimer's disease (late stage). The patient has no motor activities or language communication abilities. What are some nursing interventions the nurse can implement to promote patient interaction and communication? (Select all that apply) a. Limit interaction to verbal communication b. Use touch when appropriate c. Incorporate nonverbal communication d. Have music and imagery available during the day e. Identify yourself to the side of the patient rather than directly in front

b. Decreased sense of taste c. Decreased sense of hearing d. Impaired sense of smell

The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have​ occurred? (Select all that​ apply) a. Increased tactile sensation b. Decreased sense of taste c. Decreased sense of hearing d. Impaired sense of smell e. Increased sense of taste

c. Stop smoking

The nurse is teaching a client about lifestyle modifications to promote vasodilation in a client with peripheral vascular disease​ (PVD). Which intervention should the nurse​ suggest? a. Wash extremities in cool water b. Walk daily c. Stop smoking d. Take an aspirin daily

d. ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming."

The nurse is teaching a client with poor peripheral perfusion about the purpose of compression stockings. Which response by the nurse would be​ accurate? a. ​"You will notice that your skin will improve with the use of these stockings as they help protect your skin from​ injury." b. ​"These stockings will help to keep your blood pressure​ elevated, especially when you stand too​ quickly." c. ​"You will find that these stockings will help the heart pump more efficiently and increase the circulation to your lower​ extremities." d. ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming."

d. a decrease in the ability to hear high-pitched sounds

The nurse suspects a pt has presbycusis when she says she has which of the following manifestations? a. ringing in the ears b. a sensation of fullness in the ears c. difficulty understanding the meaning of words d. a decrease in the ability to hear high-pitched sounds

a. The students perception and learning is enhanced **With mild anxiety, the students perception and learning will be enhanced

The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety? a. The students perception and learning is enhanced b. The students attention is focused solely on studying for the examination c. The students only topic of conversation is the examination d. The student cannot talk about the examination without crying

d. Sit down, touch and spend time with him.

The patient has been in contact isolation for 4 days because of a gastrointestinal infection. His ambulation is limited, and he has had few visitors. Nursing measures should include: a. Arrange for him to have a roommate b. Turn off the lights and pull the draperies c. Assist him in a chair and bring in a flower d. Sit down, touch and spend time with him.

a. Hears better in a noisy environment

The patient who has conductive hearing loss.... a. Hears better in a noisy environment b. Hears sound but does not understand speech c. Often speaks loudly because his own voice seems low d. Experiences clearer sound with a hearing aid if the loss is less than 30 dB

a. Check for needed adaptive equipment. c. Give the patient time to respond to questions. d. Keep communication short and to the point.

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

a. High low-density lipoprotein cholesterol (LDL-C) b. Smoking d. Type 2 diabetes **Having an LDL-C value of less than 100 mg/dL is optimal. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply) a. High low-density lipoprotein cholesterol (LDL-C) b. Smoking c. Aspirin consumption d. Type 2 diabetes e. Vegetarian diet

d. An 80-year-old client admitted for emergency surgery

Which client is at greatest risk for experiencing sensory overload? a. A 40-year-old client in isolation with no family to visit b. A 28-year-old quadriplegic client in a private room c. A 16-year-old listening to loud music d. An 80-year-old client admitted for emergency surgery

a. Absence of pain or pressure

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting

c. Hypertension is usually asymptomatic until significant organ damage occurs

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients b. Most patients are able to control BP through lifestyle changes c. Hypertension is usually asymptomatic until significant organ damage occurs d. Annual BP checks are needed to monitor treatment effectiveness

a. Have the patient record dietary intake for 3 days **The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days b. Give the patient a detailed list of low-sodium foods c. Teach the patient about foods that are high in sodium d. Help the patient make an appointment with a dietitian

a. Anger **Anger is a psychological response to grief. Insomnia and decreased appetite are biological responses to grief. Personality changes are a behavioral response to grief.

Which of the following is a psychological response to​ grief? a. Anger b. Personality changes c. Insomnia d. Decreased appetite

c. Cloudy, hazy vision

Which patient finding below is associated with the development of cataracts? a. Loss of central vision b. Loss of peripheral vision c. Cloudy, hazy vision d. Black spots in vision

d. A 78-year-old man admitted to the medical unit with complications related to heart failure **Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure)

Which patient is most at risk for developing delirium? a. A 50-year-old woman with cholecystitis b. A 19-year-old man with a fractured femur c. A 42-year-old woman having an elective hysterectomy d. A 78-year-old man admitted to the medical unit with complications related to heart failure

a. An older man confined to bed at home after a stroke

Which patient would a nurse assess as being at greatest risk for sensory deprivation? a. An older man confined to bed at home after a stroke b. An adolescent in an oncology unit working on homework supplied by friends c. A woman in labor d. A toddler in a playroom awaiting same-day surgery

b. Speak normally and slowly e. Write out names or difficult words

Which strategies would best assist the nurse in communicating with a pt who has hearing loss? (Select all that apply) a. Overenunciate speech b. Speak normally and slowly c. Exaggerate facial expressions d. Raise the voice to a higher pitch e. Write out names or difficult words

c. "Walk to the point of leg pain, then rest, resuming when pain stops." **Exercise may improve arterial blood flow. Application of heat should be avoided in clients with PAD owing to lack of sensation and possible burns

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? a. "Elevate your legs above heart level to prevent swelling." b. "Inspect your legs daily for brownish discoloration around the ankles." c. "Walk to the point of leg pain, then rest, resuming when pain stops." d. "Apply a heating pad to the legs if they feel cold."

b. dying wife

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preference concerning end-of-life care for the dying wife? a. a priest b. dying wife c. hospice staff d. husband of dying wife

a. Give the client a written record of his BP to bring to his provider

While participating in a community health fair, a nurse is providing information to a client who has a BP of 150/90 mmHg during screening. Which of the following actions should the nurse take? a. Give the client a written record of his BP to bring to his provider b. Encourage the client to go to the nearest emergency department c. Instruct the client to follow-up with a provider within 6 months d. Explain to the client that he is not at risk unless he has manifestations of HTN

a. Impaired tissue perfusion

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? a. Impaired tissue perfusion b. Alteration in body image c. Alteration in activity tolerance d. Impaired skin integrity

c. Explain procedures to client, and talk as if client can hear

You are about to bathe an unconscious client. Which of the following interventions are most important on your part? a. Vary the schedule of bathing and care from day to day b. Tune the radio to client's favorite music during bath time c. Explain procedures to client, and talk as if client can hear d. Speak louder to the client than to other clients

c. Many nurses have called in sick during the past two weeks

You are the new nurse on a busy cardiac ICU. Your unit has experienced more than 8 deaths in the past month. Which of the following behaviors suggests that you and the nurses are in need of some grief counseling or support? a. Everyone is helping each other with daily tasks and care on the unit b. The unit's 'Thank You' board has had an increase in the number of messages posted during the past week c. Many nurses have called in sick during the past two weeks d. The nurses have taken turns covering each other so that the primary nurse could attend the patient's funeral, if desired

a. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." c. "It hurts to elevate my legs." d. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away." **B is a sign of CVI/PVD

You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? (Select all that apply) a. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." b. "If I stand or sit too long my legs start to feel heavy and achy." c. "It hurts to elevate my legs." d. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."

d. The patient places the drops of medication directly on the eye via the cornea **Eye drops are placed in the lower sac of the eye (conjunctival sac), NOT directly on the eye via the cornea

You're observing a patient self-administer eye drops for the treatment of glaucoma. Which finding below requires you to re-educate the patient on how to administer eye drops correctly? a. The patient refrains from blinking after instilling the eye drops b. The patient washes hands before and after administering the eye drops c. The patient uses a tissue to catch any medication that drips out of the eye after administration of the drops d. The patient places the drops of medication directly on the eye via the cornea

a. Thick, tough d. Brown pigmented **B and C are PAD

Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? (Select all that apply) a. Thick, tough b. Thin, scaly c. Hairless d. Brown pigmented