H&I All Previous pre and post tests

What happens during the sleep cycle? A) The restoration of brain tissue occurs. B) Regulation of electrolytes occurs. C) Muscles become tense. D) Immune response is suppressed.

A) The restoration of brain tissue occurs.

A multi-modal approach is most effective in treating pain. A) True B) False

A) True

For older adults, it is best to have a bedtime ritual. A) True B) False

A) True

Of the side effects of opioids, one of the most serious side effects of the use of opioids is respiratory depression. A) True B) False

A) True

The hospital nurse is instructing the nursing assistant on the care of a patient who recently had hip arthroplasty. Which of the following is the most appropriate instruction for the nurse to give the nursing assistant to prevent complications of hip fracture? A) Use a fracture bedpan for toileting needs while in bed. B) Avoid elevating the head of bed. C) Total the intake and output at the end of shift. D) Wash the client's skin with a mild soap, avoiding the dressing.

A) Use a fracture bedpan for toileting needs while in bed.

The nurse working in-home care is giving patient teaching on safety to the older diabetic client. Which of the following instructions should the nurse include? Select all that apply. A) Use adaptive devices as needed. B) Inspect the feet once a month C) Place cold fingers in hot water to warm them. D) Wearing proper foot wear will reduce the risk of trauma.

A) Use adaptive devices as needed. D) Wearing proper foot wear will reduce the risk of trauma.

The nurse is preparing educational materials for a client with hypertension. On which dietary changes should the nurse focus when preparing this material? Select all that apply. A) Using the DASH eating plan B) The effects of sodium on blood pressure C) Recognizing foods that are low in sodium D) How to read nutritional labels

A) Using the DASH eating plan B) The effects of sodium on blood pressure C) Recognizing foods that are low in sodium D) How to read nutritional labels

A nurse manager in long term care is concerned when he notices a client who is at risk for falls ambulating by himself. What should the nurse manager do first? A) Walk the client back to his room. B) Instruct the client to walk back to his room. C) Encourage him to keep walking and notify the responsible nurse taking care of him D) Get the nursing assistant to walk him back to his room.

A) Walk the client back to his room.

An 80-year-old man named John was admitted to the hospital following a motor vehicle crash, resulting in fractures. The patient has limited movement. The nurse's notes read "Client has 2 cm reddened area on the coccyx." Which of the following nursing actions are indicated at this time? Select all that apply. A) While the patient is in bed, elevate heels by placing a pillow under the legs. B) Teach the patient to increase the intake of carbohydrate intake. C) Consult with a dietician for protein supplements. D) Apply a pressure reducing mattress.

A) While the patient is in bed, elevate heels by placing a pillow under the legs. C) Consult with a dietician for protein supplements. D) Apply a pressure reducing mattress.

John undergoes surgery to repair his hip fracture. Which of the following complications should the nurse monitor for while he is hospitalized? Select all that apply. A) Wound infection B) Deep vein thrombosis C) Pain D) Muscle spasticity E) Muscle atrophy F) Pressure ulcers

A) Wound infection B) Deep vein thrombosis C) Pain D) Muscle spasticity E) Muscle atrophy F) Pressure ulcers

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) A) continuous nasogastric tube feedings B) Post surgical patient after receiving anesthesia C) stroke D) decreased level of consciousness

A) continuous nasogastric tube feedings B) Post surgical patient after receiving anesthesia C) stroke D) decreased level of consciousness

Napping for hours all day will improve long-term care residents' nighttime sleeping. A) True B) False

B) False

Taking naps helps older adults maintain good sleep hygiene. A) True B) False

B) False

The client with untreated pain will most likely have no ill effects. A) True B) False

B) False

The nurse is teaching a class on safe patient handling and mobility. What will the nurse include? (Select all that apply.) A) Place the client 1 foot away from your body prior to lifting. B) Keep the client directly in front of your body while providing care. C) Attempt to lift with a team prior to using client-handling equipment. D) Maintain a wide, stable base with your feet prior to lifting. E) Place the bed at hip level when providing direct care.

B) Keep the client directly in front of your body while providing care. D) Maintain a wide, stable base with your feet prior to lifting.

Which of the following clinical manifestations are associated with glaucoma? A) Increased depth perception B) Loss of peripheral vision C) Cloudy central vision D) Eye itching

B) Loss of peripheral vision

A 62-year-old male fell off a roof and sustained tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? A) Chronic pain B) Nociceptive pain C) Mixed pain syndrome D) Neuropathic pain

B) Nociceptive pain

A student asks the nurse, "What is the best way to assess a patient's pain?" Which response by the nurse is best? A) Objective observation B) Patient's self-report C) Behavioral assessment D) Numeric pain scale

B) Patient's self-report

Which nursing intervention is best for preventing complications of immobility when caring for a client on bedrest? A) Encouraging nutrition B) Regular turning and repositioning at least every two hours C) Frequent ambulation D) Special pressure-relief devices

B) Regular turning and repositioning at least every two hours

Which of the following is true about sleep for toddlers and preschoolers? A) Enter REM sleep immediately. B) Require approximately 12 hours of sleep a night. C) Require approximately 8 hours of sleep a night. D) Their normal biologic pattern is to sleep later and wake later than previously.

B) Require approximately 12 hours of sleep a night.

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. As you develop a plan for her care, which of the following has the highest priority? A) Chronic confusion B) Safety C) Elimination D) Impaired communication

B) Safety

An older adult with lactose intolerance requests help with menu choices. What type of food will the nurse encourage the client to avoid? A) Wheat bread B) Skim milk C) Oranges D) Prunes

B) Skim milk

The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient's pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep? A) Stage 3 B) Stage 2 C) Stage 4 D) Stage 1

B) Stage 2

Based on nutritional screening findings and assessments, which client does the nurse identify that meets criteria for surgical treatment of obesity? A) Man with a BMI of 15 B) Woman with a BMI of 42 C) Man with a BMI of 25 D) Woman with a BMI of 30

B) Woman with a BMI of 42

The nurse is caring for a patient at risk for falls. Which finding would the nurse instruct the C.N.A. to report immediately? A) A new onset of confusion B) A complaint of minor discomfort C) A blood pressure that is slightly elevated from the previous BP. D) The patient used the fracture bed pain to urinate.

A) A new onset of confusion

A patient with cancer presents to the clinic complaining of nausea, weakness, and fatigue only after receiving chemotherapy. How would you categorize the fatigue? A) Caused by a secondary acute condition B) Caused by physiologic processes C) Treatment related cause D) Has a chronic cause

C) Treatment related cause

Which of the following conditions or persons are at greatest risk for impaired sleep? Select all that apply. A) A nurse who works days one week and nights the next. B) Older adults with chronic conditions. C) Truck drivers who cross multiple time zones. D) Pregnant women E) Women with hot flashes F) Caregivers

A) A nurse who works days one week and nights the next. B) Older adults with chronic conditions. C) Truck drivers who cross multiple time zones. D) Pregnant women E) Women with hot flashes F) Caregivers

The nurse is teaching a group of clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle change does the nurse emphasize? (Select all that apply.) A) "Engage in physical activity for at least 30 minutes a day (5 days a week) or 150 minutes per week." B) "Begin a weight training program for building muscle mass." C) "Avoid fast food as it tends to be higher in fat and sugar." D) "Consume a diet that is low in salt, sugar, fats and cholesterol." E) "Eat a variety of foods, especially grain products, vegetables and fruits."

A) "Engage in physical activity for at least 30 minutes a day (5 days a week) or 150 minutes per week." C) "Avoid fast food as it tends to be higher in fat and sugar." D) "Consume a diet that is low in salt, sugar, fats and cholesterol." E) "Eat a variety of foods, especially grain products, vegetables and fruits."

A nurse is teaching home safety to the family of a client with Alzheimer's disease. The client has begun wandering around the house at night. Which of the following statements made by the family indicates an understanding of the teaching? A) "I have new locks at the tops of all outside doors." ​ B) "I will make sure he knows his address in case he wanders outside" ​ C) "I will place restraints to remind him not to get out of bed." ​ D) "I will keep the room dark at night to improve sleep." ​

A) "I have new locks at the tops of all outside doors." ​

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? A) "Patients must be moved correctly in bed to prevent shearing." B) "Patients must have a trapeze over the bed to move properly." C) "Patients should always have a two-person assist to move in bed." D) "Patients should move themselves in bed to prevent immobility."

A) "Patients must be moved correctly in bed to prevent shearing."

The nurse is explaining to the patient's family the effects of immobility. Which of the following statements should be included in the teaching? Select all that apply. A) "Patients with impaired mobility are prone to constipation." B) "Patients with impaired mobility have an increased risk for pressure ulcers." C) "Patients with impaired mobility need to have a mechanical soft diet." D) "Patients with impaired mobility are at greater risk for pneumonia."

A) "Patients with impaired mobility are prone to constipation." B) "Patients with impaired mobility have an increased risk for pressure ulcers." D) "Patients with impaired mobility are at greater risk for pneumonia."

Which patient is at greatest risk for experiencing inadequate nutrition? A) A recently widowed 76-year-old chair bound woman recovering from a recent stroke B) A 46-year-old man recovering at home from myocardial infarction C) A 55-year-old with diabetes D) A 96-year-old who lives at home and eats three meals a day

A) A recently widowed 76-year-old chair bound woman recovering from a recent stroke

A patient who had surgery is experiencing postoperative pain at 6/10 that is worsened when trying to participate in physical therapy. Which intervention for pain management is most important to include in the plan of care? A) Administer pain medications prior to therapy and as needed. B) Administer pain medication only after therapy. C) Request an order a patient-controlled analgesia with a basal rate. D) Instruct the patient on the importance of non-pharmacologic pain therapies.

A) Administer pain medications prior to therapy and as needed.

You are developing a plan for a client with osteoporosis. Which of the following interventions can you ask the C.N.A. (nurse's aid) to do? A) Assist the patient with ambulation to the bathroom and in the halls. B) Teach the importance of vitamin D and calcium in the diet. C) Monitor gait, balance and dizziness with ambulation. D) Collaborate with physical therapy to provide a walker.

A) Assist the patient with ambulation to the bathroom and in the halls.

Which of the following is a complication of immobility? A) Atelectasis B) Hip dislocation C) Muscle spasticity D) Muscle tremors

A) Atelectasis

Which of the following recommendations should the nurse give to a patient who complains of difficulty sleeping at night? Select all that apply. A) Avoid naps B) Avoid smoking C) Avoid using the bed for anything other than sleep D) Avoid alcohol E) Avoid drinking warm milk before bedtime F) Avoid caffeine

A) Avoid naps B) Avoid smoking C) Avoid using the bed for anything other than sleep D) Avoid alcohol F) Avoid caffeine

A patient has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this patient? (Select all that apply.) A) Be careful not to drop the hearing aid when handling. B) Use a toothpick to clean debris from the device. C) Soak the hearing aid in hot water for 20 minutes. D) Turn the hearing aid off when the patient goes to bed.

A) Be careful not to drop the hearing aid when handling. B) Use a toothpick to clean debris from the device. D) Turn the hearing aid off when the patient goes to bed.

Which of the following are used to determine the risk for Obstructive Sleep Apnea (OSA) prior to surgery using the STOPBANG questionnaire? Select all that apply. A) Bed partner observes the patient stop breathing B) Neck circumference larger than 40 cm C) Gender- female D) Snoring E) History of hypertension F) Daytime tiredness

A) Bed partner observes the patient stop breathing B) Neck circumference larger than 40 cm D) Snoring E) History of hypertension F) Daytime tiredness

A patient with dementia is being fed by the nursing assistant. The nurse becomes concerned when she notices the client A) Begins coughing B) Asks for more liquids to be given C) Spills their drink all over the table D) Wants someone to feed them

A) Begins coughing

The clinic nurse is planning nursing care for a 28-year-old client whose BMI is 35. Which disorders is the client at risk for? Select all that apply. A) Certain cancers B) Osteoarthritis C) Heart disease D) Type 2 diabetes E) Ulcerative colitis F) Chronic lung disease G) Hypertension H) Osteoporosis

A) Certain cancers B) Osteoarthritis C) Heart disease D) Type 2 diabetes G) Hypertension

How can nurses make it easier for a patient who wants to sleep in the hospital setting? Select all that apply. A) Cluster nursing duties. B) Put a sign on the door "do not disturb." C) Close the drapes during the evening and nighttime hours. D) Address pain issues

A) Cluster nursing duties. B) Put a sign on the door "do not disturb." C) Close the drapes during the evening and nighttime hours. D) Address pain issues

Which diagnostic test is used to determine bone strength? A) DEXA scan B) Joint x-ray C) MRI scan D) CT scan

A) DEXA scan

Which of the following disorders are associated with the correct lab levels? A) Dehydration and high sodium B) Arrhythmias and low potassium C) Cardiovascular disease and high LDL's D) Alcoholism and low thiamine E) Osteoporosis and low vitamin D F) Malnutrition and high albumin G) Iron deficiency anemia and high ferritin levels

A) Dehydration and high sodium B) Arrhythmias and low potassium C) Cardiovascular disease and high LDL's D) Alcoholism and low thiamine E) Osteoporosis and low vitamin D

A patient has a progressive functional impairment and personality changes. Is this behavior associated with dementia, delirium, or both? A) Dementia B) Both dementia and delirium C) Delirium D) No answer text provided.

A) Dementia

Which of the following is a consequence of unrelieved pain? Select all that apply. A) Developmental delays B) Increased risk for chronic pain C) Prolonged stress response D) Reduced immune competence

A) Developmental delays B) Increased risk for chronic pain C) Prolonged stress response D) Reduced immune competence

A client is crying and grimacing after surgery but denies pain and refuses pain medication. The best action by the nurse is to: A) Encourage client's expression of beliefs and emotions about the use of pain medication. B) Notify the physician of client's refusal to take pain medication. C) Administer pain medications without the knowledge of the patient. D) Talk to the family about a history of addiction.

A) Encourage client's expression of beliefs and emotions about the use of pain medication

A patient with osteoarthritis (OA) pain wants to try nonpharmacologic therapies to treat the pain. Which of the following therapies would you suggest? Select all that apply. A) Guided imagery B) Relaxation breathing C) Meditation D) Alternating ice and heat to relieve pain and inflammation E) Massage F) Icey Hot patch G) Lidocaine patch

A) Guided imagery B) Relaxation breathing C) Meditation D) Alternating ice and heat to relieve pain and inflammation E) Massage

What is the best goal for a patient with obstructive sleep apnea? A) The patient's duration of restorative sleep increases from 6 to 8 hours. B) The patient's body mass index is at 37 C) The patient can teach back the purpose of surgical management. D) The patient has a blood pressure of 160/80

A) The patient's duration of restorative sleep increases from 6 to 8 hours.

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. Which interventions would help her to function at the highest level possible? Select all that apply. A) Having her take part in activities that distract her. B) Encourage her to perform cognitive skills above her level of ability. C) Furnishing her room with familiar possessions. D) Vary the timing of day-to-day activities. E) Reducing overstimulation. F) Avoid unfamiliar situations whenever possible.

A) Having her take part in activities that distract her. C) Furnishing her room with familiar possessions. E) Reducing overstimulation. F) Avoid unfamiliar situations whenever possible.

A nurse is teaching older adults at a senior center about changes to the ears that occur with aging. What instruction would the nurse include? (Select all that apply.) A) Hearing function may be reduced because cerumen is drier and impacts more easily. B) Hearing aids can contribute to cerumen impaction. C) All adults may have some degree of hearing loss. D) Use cotton swabs to clean the ears or remove cerumen.

A) Hearing function may be reduced because cerumen is drier and impacts more easily. B) Hearing aids can contribute to cerumen impaction.

The nurse understands that neuropathic pain has which of the following characteristics? A) It is described as "a sharp, burning sensation." B) It is described as "aching, cramping or throbbing."

A) It is described as "a sharp, burning sensation."

The postoperative care of a morbidly obese patient is being planned. Which of the following interventions are needed? Select all that apply. A) Obtain an oversized blood pressure cuff and large bed. B) Contact physical therapy to provide a trapeze bar to assist with repositioning. C) Ask the nursing assistant to provide patient teaching on pain management. D) Assure adequate staffing to assist with toileting, turning and ambulation.

A) Obtain an oversized blood pressure cuff and large bed. B) Contact physical therapy to provide a trapeze bar to assist with repositioning. D) Assure adequate staffing to assist with toileting, turning and ambulation.

The most common causes of delirium for an older person include (select all that apply): A) Opioid analgesic medications B) Urinary tract infection C) Being placed in a new environment D) Anticholinergic medications E) Recent hip fracture F) Air pollution G) Pneumonia H) Foley catheter

A) Opioid analgesic medications B) Urinary tract infection C) Being placed in a new environment D) Anticholinergic medications E) Recent hip fracture G) Pneumonia H) Foley catheter

The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) A) Parents of a newborn B) Businessman who consumes six cups coffee/day C) Grandmother who takes half mile walks D) Adolescent with anorexia E) 25-year-old pregnant female

A) Parents of a newborn B) Businessman who consumes six cups coffee/day D) Adolescent with anorexia E) 25-year-old pregnant female

A nurse cares for a client who has dementia from Alzheimer's disease. Which communication techniques would the nurse implement? (Select all that apply.) A) Provide gestures when speaking B) Validate client feelings C) Use pictures when giving instructions D) Ask open-ended questions E) Provide multiple choices

A) Provide gestures when speaking B) Validate client feelings C) Use pictures when giving instructions

The nurse is planning care for a client who has decreased mobility. With which interprofessional health care team members would the nurse most likely collaborate? Select all that apply. A) Registered dietitian nutritionist (RDN) B) Registered occupational therapist (OTR) C) Respiratory therapist (RT) D) Primary health care provider (PHCP)E) Registered physical therapist (RPT)

A) Registered dietitian nutritionist (RDN) B) Registered occupational therapist (OTR) C) Respiratory therapist (RT) D) Primary health care provider (PHCP) E) Registered physical therapist (RPT)

A patient with cancer uses a transdermal fentanyl (Duragesic) patch for chronic pain. Which action by the nurse is most important for patient safety? A) Remove the old patch when applying the new one. B) Monitor the patient's bowel function every shift. C) Assess and record the patient's pain every 4 hours. D) Ensure that the patient is eating a high-fiber diet.

A) Remove the old patch when applying the new one.

The nurse is teaching a program on healthy nutrition at the senior center. Identify which points should be included in a nutrition program for older adults. Select all that apply. A) Replace ill-fitting dentures B) The importance of calcium and vitamin D for bone health C) Increase carbohydrates for energy D) Eat grapefruit to increase vitamin C in your diet E) Limit fluids to decrease risk of edema

A) Replace ill-fitting dentures B) The importance of calcium and vitamin D for bone health

A 75-year-old woman fell, and the nurse suspects she suffered a right hip fracture. What did the nurse observe? A) Right leg shorter than the left leg B) Internal rotation of the right leg C) Right calf tremors D) Unstable gait

A) Right leg shorter than the left leg

Which are treatment related causes of fatigue? (Select all that apply.) A) Side effects of medications B) Answer Surgery C) Chemotherapy D) Radiation therapy E) Blood transfusion

A) Side effects of medications B) Answer Surgery C) Chemotherapy D) Radiation therapy

A sedentary older client with osteoporosis wants to prevent hip fractures. Which of the following instructions is appropriate for the nurse to give?​ A) Start by walking short distances. B) Increase the vitamin B in your diet.​ C) Begin an aerobics class at the local gym.​ D) Avoid ambulation.

A) Start by walking short distances.

A client is disoriented to person, place, and time. Which of the following observations made by the nurse indicate the client is experiencing delirium? A) The client has disorganized thinking. B) The confusion began 5 months ago. C) The client remains awake and alert. D) The client's pupils are 4mm in diameter and respond equally to light. ​

A) The client has disorganized thinking.

The nurse is assessing a client with a BMI of 40 and concludes the client has activity intolerance. Which of the following supports the findings of activity intolerance associated with a BMI of 40? A) The client states inability to walk without becoming short of breath. B) The client states he is feeling depressed. C) The client is consuming excess carbohydrates. D) The client is too busy to exercise.

A) The client states inability to walk without becoming short of breath.

The nurse is teaching a new nursing assistant about caring for older adults and sensory perception. Which statement should the nurse include in this teaching? A) "You always need to check for earwax." B) "Face the client when you are talking to them." C) "Stand over the client and talk down to them." D) "Assess the client's hearing with the whisper test."

B) "Face the client when you are talking to them."

A nurse is providing discharge instructions to the patient after Roux-en-Y gastric bypass surgery. When the patient asks why vitamin supplements are needed what is the best response from the nurse? A) "Supplements are needed because you were given intravenous fluids during your stay here." B) "Supplements are needed because fewer nutrients are absorbed in the intestinal tract." C) "Supplements are needed because of the empty calories you regularly consume." D) "Supplements are needed because you just had surgery."

B) "Supplements are needed because fewer nutrients are absorbed in the intestinal tract."

The first 4 questions are based on this Case Study: The nurse's assessment reveals dry mucous membranes, generalized weakness, difficulty ambulating, and anorexia. His weight is down from 112 to 98 pounds over the past 3 months. His dentures are loose and poor fitting. Which result does the nurse anticipate to be abnormal based on the assessment findings? A) Liver function tests B) Albumin C) Troponin D) Red blood cell count

B) Albumin

Which client is most likely to be prescribed long term use of opioids? A) An adult client with neuropathy. B) An adult client with cancer. C) An older client with a stroke. D) A child after an appendectomy.

B) An adult client with cancer.

The mother of a two-year-old child tells the nurse she thinks her child is in pain. The nurse should: A) Notify the primary care provider of a change in behavior B) Assess the child for pain using the FLACC scale C) Assess the child using FACES scale D) Administer pain medication as prescribed

B) Assess the child for pain using the FLACC scale

Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory change? ​ A) Use minimal touch with an older adult because touch may feel uncomfortable. ​ B) Assist with preparing a bath because the client may be less able to feel the temperature. ​C) Massage with additional pressure because perception is diminished. ​ D) Use care when administering an injection because older adults experience more pain. ​

B) Assist with preparing a bath because the client may be less able to feel the temperature. ​

A nurse is caring for a client who had surgery and suddenly becomes restless. The next action by the nurse should be to A) Administer pain medications B) Check the vital signs C) Try to calm the patient D) Notify the physician

B) Check the vital signs

Which of the following is an accurate statement about the differences between dementia and delirium? ​ A) Delirium is permanent and dementia is temporary. ​ B) Delirium is acute and dementia is chronic. ​ C) Dementia has an early onset and delirium has a late onset. ​ D) Dementia can be caused by infection and delirium is caused by heredity.

B) Delirium is acute and dementia is chronic. ​

A three-year-old toddler becomes restless from ear pain during a visit to the Pediatrician's office. The nurse decides it is best to start with which of the following strategies: A) Provide a video game. B) Distract the toddler using hand puppets. C) Administer narcotic pain medication as ordered by the physician. D) Restrain the toddler.

B) Distract the toddler using hand puppets.

A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response? A) "This sleep pattern is very normal for an infant at this age." B) "Be sure you are laying the child on his back to sleep at night." C) "I recommend that you notify the child's pediatrician." D) "Adding an additional feeding will keep the child awake more."

C) "I recommend that you notify the child's pediatrician."

Which client is at greatest risk for developing delirium? A) A 59-year-old man with a history of heart disease who just had surgery. B) A 10-year-old child on the pediatric floor who has a Foley catheter in place. C) A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia. D) A 65-year-old man taking opioid analgesics for pain after a motor vehicle accident.

C) A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia.

An older adult client is at risk for undernutrition. Which nursing intervention is appropriate to ensure optimum nutritional intake? A) Administering antiemetics for nausea and analgesics for pain after meals. B) Reminding nursing assistants to allow the client to stay in bed for meals. C) Assisting the client to the toilet and providing oral care prior to meals. D) Turning on the television during meals to provide distraction.

C) Assisting the client to the toilet and providing oral care prior to meals.

A patient presents to the clinic complaining of sore throat, muscle aches, fever, and fatigue. The patient is diagnosed with Influenza. How would you categorize the fatigue? A) Has a chronic cause B) Caused by physiologic processes C) Caused by a secondary acute condition D) Treatment related cause

C) Caused by a secondary acute condition

The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address potential complications? (Select all that apply.) A) Perform a depression screen once a day. B) Decrease fluid intake. C) Consult physical therapy for range of motion. D) Allow the client to stay in a position of comfort. E) Increase fiber in the client's diet.

C) Consult physical therapy for range of motion. E) Increase fiber in the client's diet.

The first 4 questions are based on this Case Study: The nurse's assessment reveals dry mucous membranes, generalized weakness, difficulty ambulating, and anorexia. His weight is down from 112 to 98 pounds over the past 3 months. His dentures are loose and poor fitting. Which dietary item will the nurse remove from this client's nutrition tray? A) Scrambled eggs B) Toast with butter C) Granola cereal D) Applesauce

C) Granola cereal

A nurse witnesses a client with dementia eat breakfast. Afterward, the client states, "I am hungry and want breakfast." How would the nurse respond? A) "It appears you are confused this morning." B) "You ate your breakfast 30 minutes ago." C) I see you are still hungry. I will get you some toast." D) "Your family will be here soon. Let's get you dressed."

C) I see you are still hungry. I will get you some toast."

An older patient who lives alone is being discharged on opioid analgesics. Which action by the nurse is most important? A) Provide written discharge instructions. B) Give the patient follow-up information. C) Include the patient's family or friends in the discharge instructions. D) Discuss the need for home health care.

C) Include the patient's family or friends in the discharge instructions.

A client is admitted with possible sepsis. Which action should the nurse perform first? A) Administer antibiotics B) Give an antipyretic C) Obtain specified cultures D) Place the patient in isolation

C) Obtain specified cultures

Which of the following interventions help to improve communication with the resident with dementia? A) Keep the television on all day to help reorient them. B) Give long explanations with a lot of detail to the resident. C) Speak clearly and calmly to the resident. D) Ask questions while the resident is completing a task.

C) Speak clearly and calmly to the resident.

The nurse is performing a bath for a client with a spinal cord injury for which they have complete loss of movement below the neck. Which technique is appropriate to use when bathing the client's backside? A) Use of parallel bars to have the client lift themselves up B) Use a mechanical lift C) Turn the patient using a log roll technique D) Have the patient grab the side rails and rollover.

C) Turn the patient using a log roll technique

A client with osteoarthritis asks the nurse about therapies for pain. Which of the following is most likely to help relieve the pain of osteoarthritis? A) PCA pump B) Abdominal splinting C)Heat and cold D) Morphine

C)Heat and cold

A patient was recently discharged from the hospital after having sepsis. She wonders why she remains fatigued one week later. The nurse provides instructions to lessen the fatigue. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A) "I will eat more carbohydrates to improve the fatigue." B) "I will increase my caffeine intake." C) "I will increase my sleep to 12 hours per day." D) "I will walk 30 minutes a day."

D) "I will walk 30 minutes a day."

The nurse is assessing a patient's basic functional ability. Which question measures basic functional ability most accurately? A) "Do you know what today's date is?" B) "Are you able to shop for yourself?" C) "Were you sad or depressed more than once in the last 3 days?" D) "Do you use a cane, walker or wheelchair to ambulate?"

D) "Do you use a cane, walker or wheelchair to ambulate?"

A patient asks why it is so important for oral care to be completed at least twice a day. What is the nurse's best response? A) "Oral care is important to all of our clients." B) "Cleaning the surface of the teeth will prevent discoloration." C) "Oral care is performed mostly for the client's comfort." D) "It keeps the bacteria in the oral cavity under control to prevent infection"

D) "It keeps the bacteria in the oral cavity under control to prevent infection"

The nurse is caring for a client who is preparing for bariatric surgery. What is the appropriate nursing response when the client states, "I am afraid this surgery won't work"? A) "This surgery always works. It will be fine." B) "Do you think you will stay overweight for life?" C) "We will postpone the surgery until you decide how you feel." D) "Tell me what concerns you most about the surgery."

D) "Tell me what concerns you most about the surgery."

Which of the following questions should be included in a comprehensive pain assessment? A) "Are you worried about addiction to pain pills?" B) "How high would you say your pain tolerance is?" C) "Do you attach any spiritual meaning to pain?" D) "What pain rating would be acceptable to you?"

D) "What pain rating would be acceptable to you?"

A nurse in a long-term care facility is caring for a client with Alzheimer's disease who says she saw a little child under the bed, when clearly there was no little child under her bed. How should the nurse respond? A) State clearly you do not see the child under the bed. ​ B) Verify you see the child is under the bed, although you do not actually see it. ​ C) Explain to the client she needs her eyes rechecked. ​ D) Ask the client about her past to distract her from what she believes she's seeing. ​

D) Ask the client about her past to distract her from what she believes she's seeing.

A home health care nurse is planning an exercise program with an older adult who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? A) Increasing aerobic capacity B) Improving exercise endurance C) Providing personal training D) Building strength and flexibility

D) Building strength and flexibility

A 40-year-old hospitalized patient is being treated for a fractured femur and now has a PCA pump. On the hourly rounds, the nurse notes the patient has a respiratory rate of 5 breaths/minute. What is the nurse's first action? A) Document the respiratory rate in the electronic chart. B) Discontinue the opioids on the medication administration record. C) Assess the patient's blood pressure and pain level. D) Call the emergency response team and prepare to administer Narcan (Naloxone).

D) Call the emergency response team and prepare to administer Narcan (Naloxone).

A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask? A) How long are you in the rapid eye movement (REM) stage? B) Do any of your close relatives have any sleep disorders? C) Have you tried getting 10 hours of sleep instead of 8 hours? D) Do you also have any recent lifestyle or behavior changes?

D) Do you also have any recent lifestyle or behavior changes?

A client on antibiotics develops diarrhea three times a day for three days. Which action by the nurse is most important? A) Place the client on NPO until the diarrhea resolves. B) Notify the provider and recommend Imodium. C) Delegate skin care to the nursing assistant. D) Notify the provider and recommend stool cultures.

D) Notify the provider and recommend stool cultures.

A bedbound nursing home resident with osteoarthritis is refusing to drink fluids and has not urinated in 8 hours. Which nursing concept should the nurse respond to first? A) Pain B) Elimination C) Mobility D) Nutrition

D) Nutrition

A nurse is assessing pain on a confused older patient who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? A) Verbal Descriptor Scale B) Numeric rating scale C) Wong-Baker FACES Pain Scale D) PAINAD

D) PAINAD

A patient in urgent care is diagnosed with a corneal abrasion sustained while at work. Which of the following is the most important thing for the nurse to stress when giving patient instructions? A) Know where the emergency wash stations are located at work. B) Workplace policies for handling chemicals should be followed. C) Have a first aid kit available in your locker. D) Protective eye wear should always be worn.

D) Protective eye wear should always be worn.

The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse's best action? A) Cancel the patient's procedure. B) Administer an anti-anxiety medication. C) Notify the healthcare provider. D) Re-assess the patient's orientation.

D) Re-assess the patient's orientation.

Which of the following is the most important barrier to infection? A) Gastrointestinal secretions B) Colonization by host bacteria C) Inflammatory process D) Skin and mucous membranes

D) Skin and mucous membranes

The nurse enters a patient's room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from? A) Stage 2 B) Stage 3 C) Stage 4 D) Stage 1

D) Stage 1