Funds STUDY GUIDE P2

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

The spouse of a client on hospice at home is diagnosed with "caregiver burden." Which intervention(s) will the nurse use to assist the caregiver? Select all that apply.

Problem solve with the spouse to create a plan for respite Discuss support mechanisms available for the spouse Provide the name of a local caregiver support group Offer the spouse ideas for emotional coping mechanisms

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter

A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform?

heightens arousal and increases energy

The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize?

impaired concentration

An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping?

maladaptive

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms?

moderate anxiety

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

provide care transition at discharge for speech therapy

After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify?

rationalization

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing?

resistance stage

A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors?

social support

A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a (an):

stressor.

A middle-age woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are

stressors.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

Which statement made by the client indicates a need for further teaching regarding stress management?

"I manage my stress with occasional alcohol and alprazolam."

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?

"Is your mask causing discomfort?"

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes."

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

4

The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because "I got mad at her and wished she would go away." Based on this information, the nurse would estimate the sister's age to be

7 years

A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation?

Anticipatory guidance

A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs?

Attempt to calm the client and administer oxygen

The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?

Check the fit of the oxygen mask.

Which outcome(s) will the nurse include in the plan of care for a client experiencing caregiver role strain? Select all that apply.

Client will demonstrate appropriate coping strategies Client will identify support mechanisms to help with stress. Client will identify one or two stressors to eliminate.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

A withdrawn and isolated client is most likely suffering from what type of stressors on basic human needs?

Love and belonging needs

A school nurse is talking with teen related to school and home situations. The teen states, "I can't focus when I study, can't eat or sleep, and I feel like I'm going to pass out sometimes." The nurse believes the teen is experiencing which disorder?

Moderate anxiety response

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing?

Resistance stage

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply.

Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Wash hands and put on PPE, as indicated.

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation?

Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Stay indoors as much as possible.

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse?

Tell me more about why it bothers you.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing

A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of

adaptation.

A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of:

adaptation.

Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with

clear identification of the relevant problem.

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis