Final Nursing 230

The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking

b. Look at the patient when talking.

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

b. Metabolic alkalosis

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a.. Anxiety b. Not eating c. Mental health d. Not seeing family members

b. Not eating

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? a. Do nothing, no harm has occurred. b. Notify the health care provider. c. Complete an incident report. d. Assess the patient.

b. Notify the health care provider.

Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute. According to Maslow's hierarchy of needs, which patient need should the nurse address first? a. Self-esteem b. Physiological c. Self-actualization d. Love and belonging

b. Physiological

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a.. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

b. Respiratory acidosis

A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate.

b. There is an increased incidence of disease

Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who maintain perceptual biases

b. Those who develop critical thinking skills

Using Maslow's hierarchy of human needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. a. self-actualization b. air, water, and nutrition c. safety d. esteem and self-esteem needs

b. air, water, and nutrition

The nurse is preparing a patient for surgery which goal is a priority for assessing the patient for surgery? a. plan for care after b. establish a baseline c. educate the patient d. gather equipment

b. establish a baseline

Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute. According to Maslow's hierarchy of needs, which patient need should the nurse address first? a.Self-esteem b.Physiological c.Self-actualization d.Love and belonging

b.Physiological

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? a.Visceral pain b.Somatic pain c.Peripherally generated pain d.Centrally generated pain

b.Somatic pain

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? a.The patient is sleeping and is difficult to arouse. b.The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. c.Sufficient medication is left in the PCA syringe. d.The patient presses the control button to deliver pain medication.

b.The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

The nurse collects the following assessment data "right heel reedened area does not blanch." Which nursing diagnosis will the nurse assign to this patient. a. ineffective peripheral tissue perfusion b.. risk for infection

a. ineffective peripheral tissue perfusion

Ms. Dale states that she does not need the TV turned on because she cannot see very well, Normal visual changes in older adults include all of the following except: 1. Double vision 2. Sensitivity to glare 3. Decreased visual acuity 4. Decreased accommodation to darkness

1. Double vision

Caring for a patient who is having difficulty with written and spoken words. What would you expect this patient to have. a. receptive aphasia b. expressive aphasia

a. receptive apahsia

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of the cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Please the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane

A. Hold the cane on the right side. B. Keep two points of support on the floor. D. After advancing the cane, move the weaker leg forward. (E = The client should advance the stronger leg past the cane.)

A depressed patient who has not dressed in clean clothes or bathed today is reading the lunch menu but is unable to make a decision. which would the most appropriate nursing diagnosis. A. Powerlessness b. Social Isolation c. Anxiety d. Chronic Low Self-esteem

A. Powerlessness

The nurse asks the client, "What do you fear most about your surgery tomorrow?" This is an example of which communication technique? A. Providing general leads B. Seeking clarification C. Presenting reality D. Summarizing

A. Providing general leads

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B. Beneficence

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? A. Advocacy B. Responsibility C. Confidentiality D. Accountability

B. Responsibility

The patient arrives in PACU and they are unconscious what position will the nurse place the patient in post anesthesia? a. side lying with face down b. semi-prone with your head tilted

a. side lying with face down

. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? a. "I'll take my time getting up from the bed or chair." b. "I should dim the lighting outside to decrease the glare in my eyes." c. "I'll leave my throw rugs in place so that my feet won't touch the cold tile." d. "I should wear my favorite smooth bottom socks to protect my feet when walking around."

a. "I'll take my time getting up from the bed or chair."

Patient arrives at the hospital with chronic hip pain. What should the nurse include when teaching about the chronic hip pain? (Select all that apply) a. can be difficult to treat b. it lasts longer than 6 months of duration c. parasympathetic nervous system d. neurological involved

a. can be difficult to treat b. it lasts longer than 6 months of duration c. parasympathetic nervous system

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) a. The patient is hurting. b. The patient is fatigued. c. The patient is mildly anxious. d. The patient is asking questions. e. The patient is febrile (high fever). f. The patient is in the acceptance phase.

a. The patient is hurting. b. The patient is fatigued. e. The patient is febrile (high fever). (If you thought it was C (anxious) ... a mild level of anxiety would motivate a patient to learn).

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a. "Patient education is an essential component of safe, patient-centered care." b. "Patient education is a standard for professional nursing practice." c. "Patient teaching falls within the scope of nursing practice." d. "Patient teaching is documented and part of the chart." e. "Patient education is not effective with children." f. "Patient teaching can increase health care costs."

a. "Patient education is an essential component of safe, patient-centered care." b. "Patient education is a standard for professional nursing practice." c. "Patient teaching falls within the scope of nursing practice." d. "Patient teaching is documented and part of the chart."

A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases

a. Accessibility of health care services

The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

a. Advocacy

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Ask the patient to rate and describe the pain. b. raise the head of the bed c. administer pain relief medications d. call the rapid response team

a. Ask the patient to rate and describe the pain.

A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? a. Assessing own biases and attitude b. Learning about the world view of others c. Understanding organizational forces d. Developing cultural skills

a. Assessing own biases and attitude

The nurse is caring for an older adult patient who has no apparent family. When questioned about family and the definition of family, the patient states, "I have no family. They're all gone." When asked, "Who prepares your meals?" the patient states, "I do, or I go out." Which approach should the nurse use for this patient? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

a. Family as context

A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions? a. Flea bites and lice infestation b. Left at a grocery store c. Refuses to take a bath d. Cuts and bruises

a. Flea bites and lice infestation

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular' d. From intravascular to interstitial

a. From intracellular to extracellular

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

a. Health belief model

A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.) a. Homelessness b. Domestic violence c. Presence of illness d. Changing economic status e. Rise of homosexual families

a. Homelessness b. Domestic violence c. Presence of illness d. Changing economic status

=The nurse is monitoring the status of a post-op patient. The nurse would become most concerned with which sign that could indicate an evolving complication? a. Increasing restlessness b. A pulse of 86 c. BP 110/70 d. Hypoactive bowel sounds in all four quadrants

a. Increasing restlessness

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity c. Beneficence d. Nonmaleficence

a. Justice

A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. Maintaining a closed urinary drainage system b. Inserting the catheter using strict clean technique c. Disconnecting and replacing the catheter drainage bag once per shift d. Fully inflating the catheter's balloon according to the manufacturer's recommendation

a. Maintaining a closed urinary drainage system

A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice? a. Nursing theory can direct how a nurse uses the nursing process. b. Nursing theory requires the nursing process to develop knowledge. c. Nursing theory with the nursing process has a minor role in professional nursing. d. Nursing theory combined with the nursing process is specific to certain ill patients.

a. Nursing theory can direct how a nurse uses the nursing process.

The home health nurse listens to the patient's concerns about having "open-heart" surgery. The nurse explains the different surgical procedures and other options, like cardiac rehabilitation. After several visits, the patient wants cardiac rehabilitation. The nurse notifies the health care provider and sets up a referral. Which theory is the nurse using? a. Peplau's theory b. Henderson's theory c. Nightingale's theory d. Orem's self-care deficit theory

a. Peplau's theory

Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a. Provides care to transgender patients b. Provides care to restore relationships c. Provides care to patients that is individualized d. Provides care to surgical patients

a. Provides care to transgender patients

The nurse is preparing to move a client from the bed to the chair and needs to assess the client physical mobility to help. Which assessment do we perform before allowing them to move? (select all that apply) a. Range of motion b. level of consciousness c. coordination d. skin integrity e. strength

a. Range of emotion b. level of consciousness c. coordination e. strength

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? a. "Older patients often have difficulty determining what is causing their pain?" b. "As adults age, their ability to perceive pain decreases." c. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." d. "Patient who have dementia probably experience pain, and their pain is not always well controlled"

b. "As adults age, their ability to perceive pain decreases."

A client with a history of chronic back pain is questioning the need to ask for pain medication fearing he will become dependent or addicted. Which response is most therapeutic? a. "if you think you may become dependent then it is best that you do not take the medicine" b. "Taking the medicine prescribed will help you become more active and is a low risk."

b. "Taking the medicine prescribed will help you become more active and is a low risk."

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. "Your medication is scheduled for this time, and I can't adjust the time for you. You must take your pill right now." b. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" c. "This medication will still be providing you relief at the time of your dressing change." d. "Ok, swallow this pill and I will return in a minute to assess your wound"

b. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"

A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma

b. A patient 68 years old

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. No blood incompatibility occurs with a blood transfusion. b. A surgical sponge is left in the patient's incision. c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

b. A surgical sponge is left in the patient's incision.

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: a. Call social services to begin nursing home placement. b. Ask the son to step out of the room so she can complete her assessment. c. Call adult protective services because you suspect elder mistreatment. d. Assess the patient's cognitive status.

b. Ask the son to step out of the room so she can complete her assessment.

The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

b. Autonomy

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

b. Calcium of 15.5 mg/dL

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care? a. Risk for falls b. Deficient knowledge c. Risk for suffocation d. Impaired physical mobility

b. Deficient knowledge

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

b. Depression.

A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. When the nurse visits, the focus is on symptom management for the grandmother and helping the family with coping skills. This approach is an example of which of the following? a. Family as context b. Family as patient c. Family as system d. Family as structure

b. Family as patient

A nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? a. Family durability b. Family resiliency c. Family diversity d. Family forms

b. Family resiliency

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.) a. Health care provider orders restraints prn (as needed). b. Health care provider writes the type and location of the restraint. c. Health care provider renews orders for restraints every 24 hours. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used.

b. Health care provider writes the type and location of the restraint. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used.

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

b. Holistic health model

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Teaching is most effective when it responds to the learner's needs." d. "Learning consists of a conscious, deliberate set of actions designed to help the teacher."

c. "Teaching is most effective when it responds to the learner's needs."

The nursing instructor is teaching a class on nursing theory. One of the students asks, "Why do we need to know this stuff? It doesn't really affect patients." What is the instructor's best response? a. "You are correct, but we have to learn it anyway." b. "This keeps the focus of nursing narrow." c. "Theories help explain why nurses do what they do." d. "Exposure to theories will help you later in graduate school."

c. "Theories help explain why nurses do what they do."

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? a. "Ok, I will go get you some narcotic pain relievers immediately." b. "Your vitals don't show that you are having pain." c. "What would you like to try to alleviate your pain?" d. "You do not look like you are in pain."

c. "What would you like to try to alleviate your pain?"

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: a. Presbyopia. b. Presbycusis c. Cataract(s). d. Depression.

c. Cataract(s).

A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men

c. Decreased elasticity

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. b. Get an interpreter. c. Establish a rapport. d. Refer to a dietitian.

c. Establish a rapport.

. A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregivers

c. Family as system

The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

c. Family as system

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

c. Reality orientation

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.

c. Serum sodium concentration returns to normal.

A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills

c. Slower reaction time

Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

c. Socioeconomic status d. Cultural background e. Social support

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. needs to take a scheduled dose of maintenance pain medication b. needs to premeditated before walking c. The patient who is experiencing 8/10 pain and has a STAT order for pain medication d. has a PCA running that needs to have a syringe replaced

c. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow's hierarchy of needs is the nurse promoting when the family is encouraged to visit? a. First level b. Second level c. Third level d. Fourth level

c. Third level

A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? a. Deontology b. Ethics of care c. Utilitarianism d. Feminist ethics

c. Utilitarianism

A nurse is reviewing lab results which cation will the nurse observe as most abundant in the blood? a. phosphorus b. potassium c. sodium d. magnesium

c. sodium

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? a."This is the only pain medication I will need to be on." b."I can administer the pain medication as frequently as I need to" c."I feel less anxiety about the possibility of overdosing." d."I will need the nurse to notify me when it is time for another dose."

c."I feel less anxiety about the possibility of overdosing."

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? a."This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." b."The patient is sleeping, so I pushed her PCA button for her." c."I need to reassess the patient's pain 1 hour after administering oral pain medication." d."It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

c."I need to reassess the patient's pain 1 hour after administering oral pain medication."

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a.Neurological factors b.Competency of the surgeon c.Meaning of pain d.Postoperative support personnel

c.Meaning of pain

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? a. "Medications like this can be addictive, so don't take it unless you have severe pain" b. "Be sure to eat a high meal in fat before taking the medication" c. "As your pain gets better, you will begin to give yourself once-daily IM injections" d. "You need to drink plenty of fluids and eat a diet high in fiber."

d. "You need to drink plenty of fluids and eat a diet high in fiber."

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? a. Determining the need for restraints b. Assessing the patient's orientation c. Obtaining an order for a restraint d. Applying the restraint

d. Applying the restraint

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? a. Assess the patient's body language b. Observe cardiac monitor for increased heart rate c. Ask the patient to describe the effect of pain on the ability to cope d. Ask the patient to rate their pain

d. Ask the patient to rate their pain

Which action indicates the nurse is using the nursing process in patient care? a. Generates nursing knowledge for use in nursing practice. b. Conceptualizes an aspect of nursing to predict nursing care. c. Develops nursing care as a specific, distinct phenomenon. d. Delivers nursing care using a systematic approach.

d. Delivers nursing care using a systematic approach.

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

d. Frequency and opportunities for sexual activity may decline.

In viewing the family as context, what is the primary focus? a. Family members within a system b. Family process and relationships c. Family relational and transactional concepts d. Health needs of an individual member

d. Health needs of an individual member

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all four side rails in the "up" position. d. Keep the patient on fall risk until discharge.

d. Keep the patient on fall risk until discharge.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

d. Risk for injury

The nurse is assigned to care for a group of patients on a review of the medical record the nurse determines which patient is most likely at risk for fluid volume deficit. a. a patient taking corticosteroids b. a patient receiving irrigation of wounds c. a patient who has heart failure d. a patient with an ileostomy

d. a patient with an ileostomy

What modifiable factors contribute to a patient's perception of pain? a. culture b. previous pain experiences c. age and gender d. anxiety and fear

d. anxiety and fear

A patient presents to the ER flushing of the face, diaphoretic tremors. What would the nurse most likely find? a. hypercalcemia b. hypocalcemia c. hypermagnesium d. hypomagnesium

d. hypomagnesium

The patient arrives in the emergency department experiencing a headache and rates the pain as 7 on a 0-10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while waiting for orders for pain medication? a. reassure the patient that the provider will come to the ED soon b. frequently reassess the patient's pain score c. Teach the patient how to do yoga d. softly play music that the patient finds relaxing

d. softly play music that the patient finds relaxing

A nurse is using Maslow's hierarchy of needs to prioritize care. Place the levels in order of basic priority to highest priority that the nurse will follow. 1. Physiological 2. Self-esteem 3. Self-actualization 4. Safety and security 5. Love and belonging a.4, 1, 2, 3, 5 b.1, 4, 5, 3, 2 c.4, 5, 3, 2, 1 d.1, 4, 5, 2, 3

d.1, 4, 5, 2, 3

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? a.Superficial pain b.Idiopathic pain c.Chronic pain d.Visceral pain

d.Visceral pain

Atlectasis you will most likely see what?

diminished lung sounds (test question but she didn't read the question)