NRSG 327: FA Davis

Carol recognizes her primary concern is for the care of Sonia, her client. After she's completed the dressing changes, she fills out a household safety assessment form. Which comments require further teaching for the safety of Sonia's grandchildren? Select all that apply. "Billy is in a rear-facing car seat. Bobby wears a shoulder seat belt in the back seat." "Both Billy and Bobby swim with water wings at the city pool." "Billy still sucks his thumb and likes to put things in his mouth." "Bobby's favorite toys are small bricks; he leaves them everywhere." "Bobby loves his new skateboard."

"Billy is in a rear-facing car seat. Bobby wears a shoulder seat belt in the back seat." "Billy still sucks his thumb and likes to put things in his mouth." "Bobby's favorite toys are small bricks; he leaves them everywhere." "Bobby loves his new skateboard." Rear-facing seats are safer for toddlers, like Billy, up to age 4 years; it is best for children to ride rear facing as long as possible and at least until they reach the height and weight maximum specified by the seat manufacturer. Bobby, at age 6, still requires a booster seat until he reaches a height of 4 ft 9 in. and is between the ages of 8 and 12 years. Water wings at a city pool are acceptable if there are lifeguards on duty. Because Billy likes to put things in his mouth, Bobby's bricks being left out is a concern because they pose a high risk for choking. Further inquiry is needed about Bobby's skateboard; for example, where does he ride it and does he wear a helmet?

The client is being educated about the use of a walker after hip surgery. What directions by the nurse are most important before discharge? Select all that apply. "Do not lean over or pull yourself up with the walker from a sitting position" "Stand between the back two legs of the walker" "Slide the walker with each step" "Move your weaker leg forward as you move your walker forward." "Pick up your walker with each step since it has wheels."

"Do not lean over or pull yourself up with the walker from a sitting position" "Stand between the back two legs of the walker" "Move your weaker leg forward as you move your walker forward."

Mariam's first walk in the hallway went well with the assistance of two staff members. Which statements should the nurse include when returning Miriam to bed? Select all that apply. "Do not try to get up by yourself." "Perform active range-of-motion [AROM] activities hourly when in bed." "That was good; we'll try again before discharge." "Tell me about the severity of the pain you are having now." "I'll bring the bedpan if you need it."

"Do not try to get up by yourself." "Perform active range-of-motion [AROM] activities hourly when in bed." "That was good; we'll try again before discharge." "Tell me about the severity of the pain you are having now." Safety is important for all clients. Because Miriam has gotten up once, she may feel she can do so independently, which would be unsafe. Use of AROM will work best to build her muscle strength. Ambulation should take place regularly, including trips to the bathroom and activity in the hallway several times a day with assistance. Pain assessment is important before and after activity in the postoperative client.

Which statements by a nurse are correct when preventing needlesticks and blood exposure? Select all that apply. "I always place my used needles into a puncture-proof, labeled container." "I always recap my used insulin needles before disposing of them." "I confirm that the sharps container is not overfilled before placing the syringe inside." "It is okay to hand pass sharps if both people in the exchange are wearing gloves." "I use needleless systems when available."

"I always place my used needles into a puncture-proof, labeled container." "I confirm that the sharps container is not overfilled before placing the syringe inside." "I use needleless systems when available."

Which statement by the client indicates emotional distress from immobility? "I'm looking forward to being out of bed" "I don't even care if I get cleaned up or not" "I'm getting 6-7 hours of sleep each night." "There's nothing good on TV"

"I don't even care if I get cleaned up or not"

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." "Mr. Sullivan will be able to walk the length of the hallway before discharge." "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance." "Ambulate Mr. Sullivan in the hallway three times today, please."

"I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."

A client says to the nurse, "I feel so sick and weak, I don't think I'll ever be able to go home." Which response by the nurse is therapeutic? "Let's get you up and walking more; that will help." "It sounds like you are frustrated. What do you mean by 'sick and weak'?" "What can I do to help you feel better?" "I'm sure you are frustrated; you must miss being home."

"It sounds like you are frustrated. What do you mean by 'sick and weak'?"

William says to his nurse, "I guess I never really thought about how dangerous nursing can be" after learning of the needlestick. "Are injuries to nurses very common?" What would be correct responses by the nurse? Select all that apply. "Most injuries to healthcare workers are preventable." "Almost all nurses report chronic back pain." "The only ones who suffer injuries are the bedside nurses." "Several national organizations work to implement safety practices for nurses." Exposure to radiation and violence are also ways a nurse can be injured."

"Most injuries to healthcare workers are preventable." "Several national organizations work to implement safety practices for nurses." Exposure to radiation and violence are also ways a nurse can be injured." Back injuries are most common in healthcare workers with over half—not almost all—reporting chronic back pain. The American Nurses Association's "Handle With Care" initiative has brought an awareness and changes to the problem. Needlestick injury is most common in nurses and housekeeping staff. The risk for infectious disease transmission is significant, and the federal Needlestick Safety and Prevention Act and OSHA standards require tracking of such injuries. Radiation exposure is most common in those working regularly in radiological diagnostic areas. Protective shielding and a film badge are required for prevention and tracking of exposures. Violence in healthcare can occur at any time with clients, families, or coworkers. Being aware and learning good communication skills can sometimes de-escalate these situations before injury occurs.

A client comes to the emergency department with severe shortness of breath and difficulty breathing. He is restless and anxious. Which response made by the nurse offers reassurance and builds trust? Select all that apply. "I'll give you some medication to help with your breathing." "Would you like your family to stay here with you as I step out?" "Please try not to think about the breathing." "This must be a frightening situation for you." "Tell me more about what you are doing when your breathing is most difficult."

"Would you like your family to stay here with you as I step out?" "This must be a frightening situation for you." "Tell me more about what you are doing when your breathing is most difficult."

A client is experiencing signs of appendicitis with right lower quadrant pain and is being prepared for surgery. What type of pain is this client experiencing? Acute Pain Chronic Pain Intractable Pain

Acute pain Acute pain is of rapid onset and short duration, usually only a few months. It is usually associated with injury or surgery and may be indicative of a more significant injury.

Client: "I'm so terrified about this diagnosis. I'm afraid I'll never see my children grow up." Nurse, while checking the IV pump: "Oh? How old are your children?" Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Active listening The nurse in this situation is distracted by the equipment and failing to stay focused on the needs of the client. The therapeutic response would have been to stop looking at the equipment, pull up a chair to the bedside, and ask, "Tell me more about what frightens you." Active listening includes recognizing nonverbal cues, eliminating distractions, using all the senses to interpret verbal messages, and seeking clarification of unclear ideas.

The nurse caring for William gives William an injection of pain medication and then accidently sticks themself with the used needle. What measures can nurses take to prevent needlestick injuries? Select all that apply. Advocating for needleless systems Not recapping needles Disposing of sharps immediately Confirming that the sharps container is not overfilled Not hand-passing sharps from one person to another

Advocating for needleless systems Not recapping needles Disposing of sharps immediately Confirming that the sharps container is not overfilled Not hand-passing sharps from one person to another To prevent accidental needlesticks, nurses can take several measures. These include advocating for needleless systems, not recapping needles, placing the needle and syringe directly into the sharps container after use, discarding and replacing overfilled sharps containers, and not passing sharps from one person to the next.

A client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately? Droplet Airborne Contact Protective

Airborne

A nursing unit is receiving reports for five clients being newly admitted. Which client is at the highest risk for injury and best to place close to the nurse's station? A 9-year-old child who is tearful A 16-year-old adolescent who is depressed A 62-year-old patient who is anxious An 87-year-old patient who is confused

An 87-year-old patient who is confused

The diagnosis step of the nursing process includes which activity? Assessing and diagnosing Evaluating goal achievement Performing and documenting nursing actions Analyzing data

Analyzing data

After Philip gets over the initial shock of the situation, which Kübler-Ross stage of grief is he most likely to experience next? Denial Anger Bargaining Depression Acceptance

Anger Philip will initially experience denial, with statements such as, "This cannot be happening" or "I don't believe this is real." After he's worked through the feelings of shock and disbelief, he will get angry. His statement "This is not fair" demonstrate anger. The bargaining stage of grief is recognized by statements like, "If you let her live, God, I'll be the best husband and father ever." Depression is a stage that includes social isolation and, in most cases, acceptance is eventually obtained. It is hoped that Philip has a strong support system of family and friends to help him through this process.

As the days slowly pass, Mariam begins to develop psychological effects of immobility. What should the nurse be assessing for? Select all that apply. Apathy toward self-care Depression Sleep disturbances Restlessness Disorientation

Apathy toward self-care Depression Sleep disturbances Disorientation Immobility leads to isolation, regardless of where it takes place. Psychological effects of immobility include depression, anxiety, hostility, sleep disturbances, changes in ability to perform self-care, disorientation, apathy, altered body concept, and inability to concentrate, recall sequential events, and solve problems.

im, a teenager, lands on his knee during a basketball game and it begins to swell. The nurse in the audience comes to assist with his discomfort.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Application of cold Cold application causes vasoconstriction and can help prevent swelling and bleeding. It is especially effective in reducing pain as a result of procedures. Cold devices should never be in direct contact with the skin as this can cause frostbite and superficial tissue damage. Take a break at least every 15 minutes.

Katrina is experiencing lower abdominal cramping from her menstrual cycle.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Application of heat Heat promotes circulation and reduces muscle spasms from menstrual cramping. It can also be used to manage low back pain and treat nausea, vomiting, and diarrhea. Heat devices should never be in direct contact with the skin because they can cause burns to the tissue, and they should be used intermittently for no more than 15 minutes.

The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? Select all that apply. Use a narrow base stance of support. Apply a belt restraint. Get additional help. Clear the area of obstacles. Place the client in restraints.

Apply a belt restraint. Get additional help. Clear the area of obstacles.

How should the nurse deliver the breakfast tray to the bedside of a client in protective isolation? Place the tray on the table just inside the clients door Apply gloves and place the tray on the clients nightstand Apply respirator mask, gown, gloves, then place the tray in the clients room Set the tray outside the clients room

Apply respirator mask, gown, gloves, then place the tray in the clients room

Client: "I don't want another IV; you can just forget about that!" Nurse: "It's needed for your antibiotics, but if you don't want it, that's fine." Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Assertiveness The IV is important to the care of the client. Although clients are able to refuse care, the nurse needs to be assertive and explain why the IV has been ordered. Often, once the explanation is given, the client will consent.

Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Assessment The assessment of psychosocial needs is important information for the development of the care plan, which must reflect the social aspects of Mary's care.

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Assessment The nurse knows that a diet high in sodium can impact hypertension. By inquiring about dietary intake, the nurse can identify areas of education that must be included in the plan of care.

The nurse is preparing to help a client complete a bath. Which type of bath would this be? Complete bath Assist bath Partial bath Tub bath

Assist bath

Which terms are commonly used to describe types of baths delivered in healthcare. Assist bath Therapeutic bath Towel bath Ocean bath Ocean bath Partial Bath Sauna bath Bed bath Foaming bath

Assist bath Towel bath Partial bath Bed bath Therapeutic bath A bed bath is provided for clients who are bedridden and cannot bathe themselves. The bed bath may consist of various methods, including a towel bath, bag bath, basin and water bath, or a bath using prepackaged bathing products. An assist bath is given when a nurse helps a client in completing a bath, and in a partial bath the nurse cleanses only a portion of the patient's body, typically the axillae and perineum. A therapeutic bath is given for a specific purpose; for example, to treat a skin condition or relax sore muscles. There is no such thing in healthcare as an ocean, sauna, or foaming bath.

While discussing the surrounding community with Sonia, Carol learns that there are often drug dealers at the corner market, and there have been neighborhood drive-by shootings related to gang activity. What additional teaching should be included for the family? Select all that apply. Avoidance of touching needles if found Stressing a move to a different neighborhood Purchase of a guard dog for protection Proper handling of guns and gun safety How to contact 911 for emergencies

Avoidance of touching needles if found Proper handling of guns and gun safety How to contact 911 for emergencies Living in an environment with drugs, gangs, and guns places the family at a higher risk for injury. It would be important for them to be aware of the illnesses that can be transmitted with dirty needles, how to make their home safe, and gun safety to prevent accidental shootings. It is not within Carol's purview to recommend the family move or purchase a guard dog.

As Carol and Sonia are discussing safety, Carol shares that based on age group, drowning is the second leading cause of death for which family member? Billy Bobby Lily Sonia William

Billy Drowning is the second leading cause of death for children age 1 to 4 years, just behind motor vehicle accidents. Motor vehicle accidents are also the leading cause of accidental deaths in school-age children and adolescents. The leading cause of accidental death in adults is unintentional poisoning, and in the older adult it is falls.

The nurse is directing unlicensed assistive personnel in providing hour of sleep (H.S.) care for a client. What care should be provided? Select all that apply. Back care Call light within reach Brushing teeth Irrigating nose Shaving legs

Back care Call light within reach Brushing teeth

A client just learned his wife was killed in a car accident. He visits the priest and says, "I told God that I would go to church every day for the rest of my life if He would just bring my wife back." What stage of dying and grief is the client experiencing? Denial Anger Bargaining Depression

Bargaining

The nurse assists unlicensed assistive personnel in providing morning care to a client in a long-term facility. What should be included? Select all that apply. Bathing according to the client's need Massaging the back Soaking of the hands and nails Dressing in preferred clothing Transferring from the bed to a chair

Bathing according to the client's need Dressing in preferred clothing Transferring from the bed to a chair

A client is in labor and moaning and crying out during contractions. Which nonverbal response is being demonstrated? Physiological Pain Response Behavioral Pain Response Psychological Pain Response

Behavioral Pain Behavioral pain response is considered voluntary and assessments include withdrawing from painful stimuli, moaning, facial grimacing, crying, agitation, and guarding the painful area.

Nurse (while standing at the door with arms crossed, looking at the family and not the client): "We've made arrangements to transfer you to hospice care." The client thinks, "That nurse doesn't care about me." Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Body language and sharing observations Much of the communication between the client and nurse is nonverbal. When using inconsistent body language, the wrong message can be sent. In this case, the nurse should have come in, pulled up a chair, and spoken with both the client and the family, answering questions and clarifying the information being communicated. This process of using actions in combination with proper nonverbal and verbal communication would best improve communication.

Which type of drug-resistant infection is excreted in the feces? MRSA Vancomycin-Resistant Enterococci Clostridium Difficile

C. Diff Methicillin-resistant Staphylococcus aureus (MRSA) is a "super bug" that lives in the environment and is transmitted by skin-to-skin contact. Vancomycin-resistant enterococci is similar to MRSA but different medications are required for treatment. Clostridium difficile is a bacterium that thrives when the normal flora of the intestinal tract is diminished from the use of antibiotics.

Two weeks later, Carol learns that William has been hospitalized for a fractured hip due to a fall. She visits him in the hospital and observes which safety measures in place to prevent injury? Select all that apply. Call light within reach Slippers have nonskid soles Four side rails up on the bed to prevent him from getting up Bed alarm turned off because it's daytime Raised toilet seat in the bathroom

Call light within reach Slippers have nonskid soles Raised toilet seat in the bathroom The prevention of injuries and falls is important, especially in a high-risk client such as William. Nonskid slippers, a raised toilet seat and having the call light nearby are all ways to prevent falls. The use of four side rails is considered a restraint and not allowed without a healthcare provider's order. The bed alarm will also prevent falls and should be turned on at all times, not just at night.

A year after Emma's death, Philip is still unable to return to work. His mother has moved in to care for the twins and Philip feels depressed and withdrawn. What type of grief is Philip experiencing? Chronic Masked Delayed Disenfranchised Anticipatory

Chronic Chronic grief occurs when normal grief continues long term with little resolution of feelings and the inability to rejoin normal life. Masked grief occurs when a person expresses the grief through other types of behaviors, such as drinking or arguing. In delayed grief, the grief process is not addressed at the time of the loss and occurs at a later time. In disenfranchised grief, the loss is not socially supported, as often occurs in a miscarriage or loss of an unrecognized homosexual relationship. Anticipatory grief is experienced before the actual physical loss; for example, when someone is ill for a long time.

A client has rheumatoid arthritis. The pain impairs their ability to be physically active. The client describes that there are bad days and worse days, but the pain is always there. Acute Pain Chronic Pain Intractable Pain

Chronic Pain Chronic pain lasts several months or longer and may interfere with activities of daily living. It is often a result of a progressive disorder and can come and go with remission and exacerbation. It often is accompanied by a psychological pain response.

The nurse delivers the first dose of a new blood pressure medicine that the client has not taken previously. She assesses the blood pressure before delivery of the medication and 1 hour afterward. Prior to the second dosage, the patient's blood pressure is very low and the nurse decides to hold the medication. Clinical Judgement Not Clinical Judgement

Clinical Judgement With the patient's best interest in mind, the nurse has gathered data, evaluated the data, and made decisions based on the information.

A nurse decides to place the intravenous catheter into the client's left arm because he is right handed. Clinical Judgment Not Clinical Judgment

Clinical Judgement Taking patient considerations into account when inserting an intravenous catheter demonstrates clinical judgment.

A client tells the nurse that the hospital food is "terrible." The nurse asks what foods the client would prefer based on his cultural customs. She then contacts the dietary department to determine whether adjustments can be made. After the next meal, the nurse asks the client whether the food has improved. Clinical Judgment Not Clinical Judgment

Clinical judgement The nurse has identified a problem, assessed the client's individual needs, made adjustments to care, and evaluated whether the changes were effective.

The nurse discovers abnormal findings when performing a physical assessment. She reviews the electronic health record, comparing the findings, and calls the healthcare provider with the contrasting information. The nurse practitioner then gives new medication orders. Clinical Judgment Not Clinical Judgment

Clinical judgement The nurse performed further investigation to determine whether the findings were new or had been previously reported. Further reporting identified that additional follow-up was required.

The nurse delivers the first dose of a new blood pressure medicine that the client has not taken previously. She assesses the blood pressure before delivery of the medication and 1 hour afterward. Prior to the second dosage, the patient's blood pressure is very low and the nurse decides to hold the medication. Clinical Judgment Not Clinical Judgment

Clinical judgement With the patient's best interest in mind, the nurse has gathered data, evaluated the data, and made decisions based on the information.

The nurse recognizes that the client has crackles in the lower lung fields from an accumulation of fluid. He further explores the patient's weight, intake and output, and medication list before documenting the findings. Clinical Judgment Not Clinical Judgment

Clinical judgment Further inquiry allows the nurse to determine the severity of the findings and whether additional intervention is necessary.

The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply. Confusion Guarding Poor eye contact Moaning Irritability

Confusion Guarding Moaning Irritability *NOT Poor eye contact

Ron is experiencing phantom pain after a left below-the-knee amputation.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Contralateral Stimulation Phantom pain occurs when a limb has been amputated. The client will continue to feel pain as though the extremity were still present. Doctors once believed this postamputation phenomenon was psychological, but experts now recognize that these real sensations originate in the spinal cord and brain. Contralateral stimulation is the stimulation of the skin in an area opposite to the painful site by scratching, rubbing, or applying heat or cold. In this case, the stimulation would occur to the right lower leg.

The nurse, Peter, knows that Mariam is at a higher risk for injury as a result of her immobility. Which assessment changes indicate a potential complication of immobility? Select all that apply. Crackles in both lung bases Edema of the feet Reddened areas on the coccyx Increased appetite Diarrhea

Crackles in both lung bases Edema of the feet Reddened areas on the coccyx There are many hazards resulting from immobility. Stress on the muscle and bones leads to muscle atrophy and joint stiffening. Hypoventilation leads to fluid accumulation in the alveoli of the lungs. Circulatory concerns include venous pooling, edema, and fluid in the tissue leading to skin breakdown. A person will also experience orthostatic hypotension from the pooling of blood. Metabolism slows, decreasing appetite; peristalsis decreases, leading to paralytic ileus; and urine stagnates in the bladder, increasing the risk of infection and stone formation.

Which are vital components of exemplary patient care? Select all that apply. Critical thinking Problem-solving Clinical reasoning Data collection Decision making

Critical thinking Problem-solving Clinical reasoning Decision making

A client was 17-years-old when she lost her mother, and she placed all her energy into caring for her three younger siblings. Two years after her mom's death, a casual acquaintance was killed in a car accident. She tells the nurse, "This is bringing back memories of my mom's death. I'm having a harder time now than I did at the time of her passing." What type of grief could the client be experiencing? Chronic Disenfranchised Masked Delayed

Delayed

Which are the stages of grief as defined by Elisabeth Kübler-Ross? Select all that apply. Frustration Denial Acceptance Depression Fear

Denial Acceptance Depression

Which factors impact a persons perception of pain? Select all that apply. Developmental stage Developmental age Location Culture and environment Cognitive impairment

Developmental stage Developmental age Culture and environment Cognitive impairment *NOT LOCATION

Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Diagnosis Diagnosis includes the analysis of the data collected. This is the thinking phase needed to link the problems to the plan of action.

The nurse notices a blood pressure cuff in the client's room with spots of dried blood on it. What should be the nurse's next action? Clean it with a wet rag Disinfect it with a chemical cleaner Sterilize it with an autoclave Report it to the charge nurse

Disinfect it with a chemical cleaner

Which process in maintaining a clean environment includes the removal of pathogens using chemicals? Cleaning Disinfecting Sterilizing

Disinfecting Cleaning a surface removes visible soil, such as occurs when a nurse uses a wet washcloth to wipe up a food spill on a client's overbed table. Disinfecting uses chemicals, steam, gas, or ultraviolet light to remove all pathogens. It is not a guarantee that all pathogens are eliminated, but it significantly prevents transmission. A nurse using a cleaning solution to wipe down an IV pole before moving it to another patient's room is disinfecting it. Sterilizing is the elimination of all microorganisms with the use of autoclaving with moist heat, ethylene oxide gas, or dry heat. Equipment used in the operating room is sterilized using these processes.

The nurse just gave an immunization to Jonathan, a 2-year-old.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Distraction Distraction allows the nurse to pull the patient's attention away from the pain by focusing on toys, videos, or sound. It is most effective with children for mild to moderate pain and for brief periods of time.

As the family discusses with the healthcare team the possibility of removing Emma from life support, what questions should be considered before a decision is made? Select all that apply. Does Emma have an advance directive? What do Emma's parents want? Who is the healthcare proxy? Who will raise the children? What would Emma want?

Does Emma have an advance directive? Who is the healthcare proxy? What would Emma want? The first step in the legal process is to determine whether Emma has an advance directive and whom she has designated as the healthcare durable power of attorney. If there is no advance directive, the healthcare proxy would have been delineated upon admission and is responsible for making decisions. Often, this process is made easier by considering what the person would have wanted. Although it is kind to consider the opinions of other family members, the ultimate decision is made by the healthcare proxy.

What should the nurse include in morning care? Dressing Toileting Shaving Transferring to chair Backrub Chaning the linen Tidy the room

Dressing Toileting Shaving Transferring to chair Changing the linen Tidy the room Morning care occurs after breakfast. Depending on the patient's self-care ability, assist with toileting, bathing, oral hygiene, skin care, hair care (including shaving if needed), dressing, and positioning or helping the patient transfer to a chair. Change or straighten bed linens according to agency policy and tidy the room.

Emma's care is transferred to hospice and the family prepares for her eventual death. What advantages would this provide?Select all that apply. Emma will receive holistic care. Visitation from family and friends will be unlimited. Support for Philip will be available. The twins will be able to stay with their mom. Support groups will continue after Emma dies.

Emma will receive holistic care. Visitation from family and friends will be unlimited. Support for Philip will be available. The twins will be able to stay with their mom. Support groups will continue after Emma dies. Hospice offers end-of-life care supporting quality of life and death with dignity. The team approach of hospice considers the entire family in the plan of care. Hospice offers a full team of support, including nurses, case managers, social workers, therapists, and clergy.

Client: "You told me you would speak to my doctor about getting my pain medication increased. Were you able to do that?" Nurse: "Oh, I decided we could wait until the doctor makes his rounds this evening and ask then." Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Establishing trust To establish trust the nurse must be respectful, greet the client by name, listen actively, respond honestly, and be open and consistent in the care. This includes doing what you told the client you would do.

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Evaluation

The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient's family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Evaluation With the evaluation of the plan of care, constant reappraisal is required and alterations are made in the original plan to ensure its currency and relevance.

Client: "My stomach hurts." Nurse: "I'll get you some pain medicine." Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Exploring issues When a client expresses a symptom, the nurse must explore further to see whether something more severe is happening. In this case, the nurse should have completed a pain assessment.

Donna would like a way to manage her pain on a long-term basis. She struggles with the emotions that come from living with chronic pain.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Expressive Writing Expressive writing helps reduce chronic pain by allowing for an outlet of emotions, fear, and frustration common when dealing with pain on a daily basis.

Which pain scales are used to determine a client's level of pain? Select all that apply. OPQRST-AAA FACES Visual analog scale Numeric rating scale The intensity word scale

FACES Visual analog scale Numeric rating scale

An older adult who lives alone has fallen and fractured the left hip. The client cannot get to the phone to call for help. The pain worsens as time passes and the client becomes confused waiting for someone to come. What factors are exacerbating the situation? Select all that apply. Fear Helplessness Cognitive impairment Need to be independent Hunger

Fear Helplessness Cognitive impairment

Suzie, the nurse performing the grief and loss assessment on Philip, feels very uncomfortable asking personal questions. What could be some reasons for this response? Select all that apply. Fear of expressing emotion Unresolved personal grief issues Caring too much Fear of her own mortality Relating too much to his situation

Fear of expressing emotion Unresolved personal grief issues Fear of her own mortality Relating too much to his situation Several things can create a barrier to end-of-life conversations, including fears of one's own mortality, unresolved personal grief issues, lack of experience in dealing with death and dying, fear of expressing emotion, fear of not knowing an answer, not knowing whether to give an honest answer, not understanding a person's culture, and insensitivity.

Which findings in the immobile client are complications related to immobility? Select all that apply. Fluid in the lungs Decreasing appetite Muscle growth Constipation Bladder infection

Fluid in the lungs Decreasing appetite Constipation Bladder infection

Which precaution should the nurse use when setting up a client's food tray? Transmission Based (Tier 2) Handwashing only Standard (Tier 1)

Handwashing only Setting up a client's food tray is not an infection control concern if the client does not have symptoms of an infection. Gloves may be used when clearing a food tray, which is a greater health concern.

The nurse is preparing for heat and cold application. Which of the following statements are true? Select all that apply. Heat/cold devices can cause superficial tissue damage Heat/cold devices should never come in direct contact with the skin Heat/cold devices should be used intermittently Heat/cold devices are safe to use for all clients Heat/cold devices should be in place for 30 minutes at a time

Heat/cold devices can cause superficial tissue damage Heat/cold devices should never come in direct contact with the skin Heat/cold devices should be used intermittently

The healthcare providers said that Emma has experienced brain death. What does that mean for her physical functions? Select all that apply. Her heart is beating without artificial means. Breathing requires a ventilator. Cognitive functioning is intact. A pacemaker has been placed to keep her heart beating. She can grimace and cry.

Her heart is beating without artificial means Breathing requires a ventilator eart-lung death is defined by the irreversible cessation of blood flow and breathing. Evaluating brain death is a little more complicated. The level of brain function varies depending on the involvement of the brainstem. If there is brainstem involvement, the body cannot sustain normal functions, such as temperature control and breathing, without artificial means. A higher-brain death involves the impairment of cognitive functioning, consciousness, memory, and reasoning, placing a person in a persistent vegetative state.

Philip and Emma are a young married couple expecting twins. They have spent years trying to conceive and were finally able to do so with artificial insemination. Both babies, a boy and a girl, were born small but healthy. The night after delivery, Emma suffers a significant brain hemorrhage and is placed on life support. In the next few days, her family is told she is brain dead and only being kept alive by the machines. They are asked to consider withdrawing life support, allowing her to die. What factors will impact Philip's grieving process? Select all that apply. His attachment to his wife Support of family and friends Previous experiences with loss Cost of the hospitalization Spiritual beliefs

His attachment to his wife Support of family and friends Previous experiences with loss Spiritual beliefs Many things impact a person's grief process, including the significance of the loss, support systems, conflicts occurring at the time of death, circumstances of the loss, previous loss experience, spiritual and cultural beliefs, and the timing of death. Having two babies to care for could make Philip's grief process easier or more difficult. For some people, the "busyness" of twins will keep the mind occupied and delay the grieving process; for others, the twins will be a constant reminder of the lost spouse, which could have a positive or negative impact.

What types of scheduled hygiene are provided in healthcare facilities? Hour of sleep care Hourly rounds Mid-day care Early morning care Morning care Before dinner care Afternoon care Middle of the night care

Hour of sleep care Hourly rounds Mid-day care Early morning care Morning care Afternoon care Scheduled hygiene care in a facility includes hourly rounds (positioning, pain relief, toileting), early morning care (toileting, wash face, oral care, breakfast preparation), morning care (toileting, bathing, oral hygiene, skin care, hair care, shaving, dressing, positioning or helping the patient transfer to a chair, changing or straightening bed linens, and tidying the room), afternoon care (necessary hygiene, preparation for afternoon rest and visitors), and hour of sleep care (back massage, oral care, turning out lights, placing call light and night stand within reach).

The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? Select all that apply. Increased urine output Hypertension Fever Nausea and vomiting Pneumonia

Hypertension Fever Nausea and vomiting

The decision is made to withdraw life support from Emma and she is changed to "DNAR" status. What does this designation mean for the healthcare team? If she stops breathing, she will be given oxygen. If she cardiac arrests, no action will be taken. Cardiopulmonary resuscitation may be initiated. The family will decide what actions will be taken. She will be transferred to hospice care.

If she cardiac arrests, no action will be taken. "Do Not Attempt Resuscitation" (previously known as Do Not Resuscitate [DNR]) means that if a patient experiences cardiac or respiratory failure, attempts will not be made to resuscitate them. Because of the legalities of this situation, nurses must closely follow the policy of their agencies and the laws of their state. A DNAR order does not mean "do not treat," so a client will continue to receive medications, nutritional support, and fluids unless stipulated otherwise.

Sarah fell while downhill skiing and fractured her tibia. The bone has a compound fracture and has broken through the skin.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Immobilization Immobilization of a painful body part with splints can offer some relief. Because Sarah will need to be moved, splinting is especially helpful in preventing further tissue damage and minimizing pain.

Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Implementation The implementation phase of the nursing process is the "action" phase. The injection given by the nurse is the action performed to control Mr. Thompson's pain and allow him more comfort with activity.

Mrs. Clancy is a nursing home resident at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Implementation This is an example of delegation, part of the implementation phase of the nursing process.

Miriam is excited to go home. Which of the following are key elements of discharge planning? Select all that apply. Include her husband during instructions. Arise from bed slowly to prevent or reduce dizziness. Remove loose rugs and obstacles that may cause problems. Stop using the walker when she's feeling strong enough. Walk around the block several times a day independently.

Include her husband during instructions. Arise from bed slowly to prevent or reduce dizziness. Remove loose rugs and obstacles that may cause problems. The inclusion of her caretaker is beneficial to support her discharge teaching plan. Although she is better, she is still weak from extended bedrest. Care must be taken when arising and while ambulating to avoid another fall.

Mariam is an active 69-year-old. She leads the pool aerobic exercise group in the senior retirement community that she and her husband moved to 3 years ago. She walks 2 miles each morning and eats a healthy, balanced diet. She is from a family with longevity and trusts she will have good health well into her 90s. As Mariam is walking to her exercise class, she steps off the curb and falls. She is taken to the emergency room and diagnosed with a fractured hip. She must be on bedrest and in traction for a week before surgery is scheduled. During that time, the pain is significant and she requires a large amount of pain medicine. Which factors contribute to her immobility? Select all that apply. Age Injury Nutritional status Abuse of body Stress

Injury and Stress Many things impact a person's mobility, including age, with young and old at highest risk; being obese or very frail; nutritional status; wear and tear, such as experienced by a manual laborer or athlete; stress level; environmental factors; and health status. Mariam is older but very active, so her age is not impacting her immobility, the injury is. The stress of hospitalization and the need for pain medicine are both decreasing her mobility.

A client experienced a back injury at work. The pain shoots down the left leg and it is impossible to find a comfortable position that relieves the distress. The client has tried every pain management suggestion and multiple prescription pain medications with minimal relief. Acute Pain Chronic Pain Intractable Pain

Intractable Pain Intractable pain is highly resistant to relief. It is especially frustrating for the patient and caregiver because multiple interventions and medications are tried without adequate pain relief.

The nurse is caring for a client who has recently immigrated to this country. The family shares that the client usually bathes once a week. When your assessment is finished, the nurse hopes to have the client shower. What additional information needs to be discussed? Explaining the importance of showering daily Sharing the shower schedule for clients in the facility Learning more about the client's standard hygiene practices Determining the client's level of body odor

Learning more about the client's standard hygiene practices

Which type of pain scale uses illustrations to help describe pain? The Simple Descriptor Scale The Numerical Rating Scale The Wong-Baker FACES Pain Rating Scale

The Wong-Baker FACES Pain Rating Scale The Wong-Baker FACES pain rating scale was originally designed for children but is now used in many settings, especially for those with communication or cognitive impairments. This scale is also helpful if the client speaks a different language from that of the healthcare providers.

Which techniques are beneficial in bathing a client with dementia? Play loud music as a distraction Let the client know what you are going to do before touching them with or spraying water Do not rush Provide choices Provide privacy Bathe the client only once a week Use a gentle shower head for rinsing Explain the procedure simply

Let the client know what you are going to do before touching them with or spraying water Do not rush Provide choices Provide privacy Use a gentle shower head for rinsing Explain the procedure simply Techniques for bathing clients with dementia include those that are low stimulus and slow moving and give the client some sense of control by allowing them to make decisions and help as possible. It is important for the focus of care to be on the patient and not on the procedure.

The client has a reddened area around their IV site. It is tender to touch. Which type of infection is this? Localized Systemic Endogenous Healthcare-Related Infection

Localized A localized infection occurs and stays in a specific part of the body. If an infection becomes systemic, the pathogen will invade the blood or lymph and spread throughout the body, perhaps causing septicemia. When an infected IV site is not treated promptly, a systemic infection is probable. An endogenous healthcare-related infection is a secondary infection that results from treatments that lower the body's normal immune responses. In exogenous healthcare-related infections, the pathogen is acquired in the healthcare environment, often from medication interventions like IV therapy and indwelling catheters.

What is the best way for a nurse to develop clinical judgment skills? Practice memorizing clinical assessment findings. Look for clinical changes and question why. Ask for assistance when abnormalities are found. Learn more about the clinical judgment process.

Look for clinical changes and question why.

Which of the following may cause grief and loss? Select all that apply. Losing a political office Amputation of a toe Demotion of a job position Loss of a pet Inability to have children

Losing a political office Amputation of a toe Demotion of a job position Loss of a pet Inability to have children

The nurse is speaking with a group of nursing students about the use of heat and ice for pain control. Which situations are best for this modality? Select all that apply. Acute abdominal pain Low back with spasticity Activity-induced muscle pain Pain from obstetric procedures Migraine headaches

Low back with spasticity Activity-induced muscle pain Pain from obstetric procedures

The nurse is providing comfort to a person who has fallen on the hiking trail and broken his ankle. Which techniques can be used until medical help arrives? Select all that apply. Massage Relaxation Meditation Controlling breathing Imagery

Massage Relaxation Meditation Controlling breathing Imagery

Esther puts on her call light during the night, telling the nurse that her back aches from being in bed so long and she cannot sleep.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Massage Massage is effective in relaxing muscles, reducing pain, and promoting sleep. The nurse should use slow, long strokes for the best level of relaxation, especially in the laboring and bed-bound client. The nurse should obtain verbal consent first because some people are uncomfortable being touched.

Two nurses are planning to transfer a client out of bed. Which devices could be used? Select all that apply. Mechanical lift Trapeze bar Transfer belt Footboard Scoot sheet

Mechanical lift Trapeze bar Transfer belt Scoot sheet

At discharge, Miriam is instructed to continue using a walker until the follow-up visit with her surgeon in 2 weeks. What instructions need to be included with the use of the walker? Advance the walker far ahead of your body and walk toward it. Slide the walker with each step. Move your weaker leg forward as your walker moves forward. Stand well behind the back legs. Size does not matter; any size walker will work.

Move your weaker leg forward as your walker moves forward. A walker should be the proper fit based on the person's height. It is important that she does not have to lean over or reach up to reach the device. A person should stand between the back legs, not too far behind the walker. Pick up the walker and advance with each step. It should not be pushed ahead. The weaker leg should move with the walker and the walker should be picked up, not slid, unless it has wheels.

The unlicensed assistive personnel reports to the nurse that the blood pressure for a client is very low. The nurse reports the information to the next shift. Clinical Judgment Not Clinical Judgment

Not clinical judgement A critical-thinking nurse would question the results, reevaluate the findings, and confirm that the information is correct. If the findings are correct, the critical-thinking nurse would then determine next steps.

Without assistance, a student ambulates a client in the hallway who recently returned from surgery. Clinical Judgment Not Clinical Judgment

Not clinical judgement Clients can be unstable after surgery and there are several reasons for concern, including dizziness, incisional damage, bleeding, and changes in vital signs. The nurse must be aware of the individual client's needs when determining when and how to ambulate the client for the first time after surgery.

The nurse gathers equipment for the insertion of a Foley catheter, obtains a verbal consent from the client, and follows the agency's procedure to complete the task. Clinical Judgment Not Clinical Judgment

Not clinical judgement The nurse is completing a task that follows a specific step-by-step procedure and thus does not require clinical judgment.

The student explores the client's health record, reads the history and physical examination, and records the information on the nursing care plan. Clinical Judgment Not Clinical Judgment

Not clinical judgement The process of data collection and recording does not require critical-thinking skills.

Philip's mom convinces him to seek assistance from his family practitioner for his behavior changes. What should the nurse include in the assessment of grief and loss? Select all that apply. Nutritional intake and weight Emotional feelings of helplessness and depression Behaviors of forgetfulness and crying Changes in sleep patterns Willingness to become more socially active

Nutritional intake and weight Emotional feelings of helplessness and depression Behaviors of forgetfulness and crying Changes in sleep patterns The assessment for grief and loss should include a physical assessment, including nutritional intake, weight loss/gain, fatigue, decreased libido, energy level, and other physical symptoms. The nurse will perform an emotional assessment for feelings including anger, sadness, guilt, and others. Behavior changes may include forgetfulness, insomnia or oversleeping, dreams of the deceased, and loss of productivity. Cognitive changes may include impaired judgment, obsessive thoughts of the deceased, preoccupation, and confusion.

What is included in the nurse's ability to make a clinical judgment decision? Select all that apply. Observation and assessment of the presenting situations Identification and prioritization of concerns Generation of evidence-based solutions Evaluation of outcomes of the solutions Continuous adjustment of care

Observation and assessment of the presenting situations Identification and prioritization of concerns Generation of evidence-based solutions Evaluation of outcomes of the solutions Continuous adjustment of care

Mariam has returned from surgery and is prescribed to begin increasing activity. Peter is prepared to help her get up for the first time. What is the most important action before beginning? Obtain a walker. Obtain a gait belt. Remove all obstacles. Obtain additional assistance. Determine level of motivation.

Obtain additional assistance Mariam has been on bedrest for a week, had surgery, and is likely under the influence of anesthesia or pain medicine. She is at high risk for dizziness, weakness, and falling, so the nurse needs additional assistance before attempting to help her out of bed.

Which intervention in the immobile client's plan of care best helps develop muscle strength? Consume a diet high in protein Perform active range of motion each hour Use overbed trapeze to pull yourself up in bed Log-roll client every two hours

Perform active range of motion each hour

What factors influence hygiene practices? Personal Preferences Culture and Religion or Spirituality Economic Status Environment Developmental Level Knowledge level Employment status

Personal Preferences Culture and Religion or Spirituality Economic Status Environment Developmental Level Knowledge level People have different practices and beliefs related to hygiene. Many factors influence these beliefs, including personal preferences, culture, religion, spirituality, economic status, living environment, developmental level, and knowledge/cognitive level. Employment status and college education are not considered influences.

The nurse is teaching a family about phantom pain. Which statement is correct? Phantom pain occurs before an amputation The pain is deadened from surgery Phantom pain is a psychological condition Phantom pain is real and should be treated as such

Phantom pain is real and should be treated as such

A client is experiencing chest pain and shortness of breath with tachycardia, hypertension, and tachypnea. Which nonverbal response is demonstrated? Physiological Pain Response Behavioral Pain Response Psychological Pain Response

Physiological Pain Response The physiological pain response is involuntary and includes both sympathetic and parasympathetic responses. The sympathetic responses are seen in acute pain and include increased systolic blood pressure, heart rate, respiratory rate, dilated blood vessels to the brain, increased alertness, dilated pupils, and rapid speech. The parasympathetic responses are a result of deep or prolonged pain and include decreased diastolic blood pressure, syncope, decreased heart rate, changeable breathing patterns, withdrawal, constricted pupils, and slow, monotonous speech.

As the nurse prepares to help William get out of bed for the first time after surgery, which safety measures should be taken? Select all that apply. Place skid-resistant shoes on William. Place a belt restraint tightly around William's waist. Get additional help. Clear the area of obstacles. Place a skid-free rug at the side of the bed.

Place skid-resistant shoes on William. Place a belt restraint tightly around William's waist. Get additional help. Clear the area of obstacles. In this situation, both William and the nurse are at risk for injury. It is important for there to be adequate help, a belt restraint, skid-resistant shoes, and a clear area for ambulation. Placing a skid-free rug will not help as William moves off the rug.

Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying client needs. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Planning interventions Intervention planning must include current best practices. Evidence-based policy will validate that the client is receiving research-based interventions in their plan of care.

The nurse, Linda, identifies some concerns about her client's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Planning outcomes Discharge planning should begin at admission. This process can often take days to coordinate and may prolong the client's hospital stay if not started right away. This identification of discharge needs is a part of planning patient outcomes.

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center." Select the step of the nursing process this represents. Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Planning outcomes This statement documented in the client's record is a long-term goal, a part of planning outcomes. Care plan goals are both short-term and long-term. A short-term goal would be "no falls will occur in the next 24 hours" or "client will ask for assistance each time she gets out of bed."

Peter develops an immobility plan of care for Mariam. What should be included? Select all that apply. Position to allow for lung expansion. Massage calves and legs each shift. Encourage visitors. Eat a healthy balanced diet. Turn every 2 hours.

Position to allow for lung expansion. Encourage visitors. Eat a healthy balanced diet. Turn every 2 hours. Positioning is important for lung expansion, circulation, and prevention of skin breakdown. A healthy, balanced diet can prevent loss of muscle mass. Visitors can help combat the psychological impact of immobility. Massaging calves and legs is contraindicated because of the risk of thrombi formation.

The nurse recognizes that a client's respiratory rate has increased from 16 to 24 over the last 2 hours. What action should the nurse take? Record the findings only. Prioritize the need for further inquiry. Evaluate the effectiveness of the solutions. Generate the best solutions.

Prioritize the need for further inquiry.

Which type of environment best protects a client who is immunosuppressed and at high risk for acquiring an infection? Protective Isolation Contact Isolation Airborne Isolation

Protective Isolation Protective isolation is used when a severely immune-compromised client is at high risk of acquiring an infection. Additional steps must be taken to clean equipment and the environment and restrict visitors. The nurse must wear a mask, gown, and gloves when providing patient care.

The nurse is bathing a client with senile dementia. What action will optimize the chance of cooperation? Complete the bath quickly. Provide privacy, allowing for choices. Have other people present to assist. Avoid bathing more often than necessary.

Provide privacy, allowing for choices

A client has degenerative joint disease and experiences pain with any physical activity, including walking. The client is irritable and wants to be left alone to sleep all the time. Which nonverbal response is being demonstrated? Physiological Pain Response Behavioral Pain Response Psychological Pain Response

Psychological Pain response Psychological or affective responses are a result of the mental impact of the pain. These can include anxiety, depression, anger, fear, exhaustion, hopelessness, and irritability.

A nurse observes an interaction between a client and another healthcare team member. Which observations demonstrate active listening by the team member? Select all that apply. Recognizing nonverbal cues by the client Eliminating intrusions and distractions in the room Using all the senses to interpret verbal messages Seeking clarification of unclear ideas Limiting the use of direct eye contact

Recognizing nonverbal cues by the client Eliminating intrusions and distractions in the room Using all the senses to interpret verbal messages Seeking clarification of unclear ideas

Michael experiences chronic low back pain. The pain is especially significant while bending to put on his socks and shoes.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing

Relaxation Techniques Relaxation techniques are useful for reducing chronic pain. For Michael, knowing that bending exacerbates the pain will make it worse with anticipation. Relaxation techniques would help minimize the discomfort.

The nurse is performing an assessment on a client. What should be included in this process? Ability to pay for hospital stay Who brought the patient to the hospital Level of education Religious and spiritual needs

Religious and Spiritual needs

A nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are actions the nurse can take when caring for this client? Select all that apply. Repeat fall risk assessment every 8 hours. Place call light within reach. Request a social service consultation. Identify medications that increase falling risk. Restrain the patient to the bed.

Repeat fall risk assessment every 8 hours. Place call light within reach. Identify medications that increase falling risk.

Which example of personal protective equipment is unique to transmission-based precautions? Surgical Mask' Face Mask Respirator Mask

Respirator Mask The respirator mask (N-95) is used for airborne precautions. It is specially designed to protect the healthcare worker from small airborne organisms. Special training is needed to confirm that the mask is worn properly and fitted tightly enough for protection.

Client: "I don't want to learn about my new medications right now." Nurse: "All right." (Documents that the patient refused, and reports this in handoff report.) Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Restating, clarifying, and validating messages It is important for the nurse to seek clarification when care is refused, as the refusal may stem from exhaustion or pain. A better response would be to say, "It is important that you understand these medications and how to safely take them. Tell me why you don't want to learn about them."

As an older adult, which age-related changes contribute to William's risk for injury? Select all that apply. Risk-taking behavior Sensory losses Slowing of reflexes Decreased mobility Increased cognitive awareness

Sensory losses Slowing of reflexes Decreased mobility An individual's risk factors for injury include impairment in lifestyle (smoking, alcohol ingestion, risk-taking behaviors), decreased cognitive awareness (confusion), sensory and perceptual status (loss of senses), impaired communication (language barriers), impaired mobility, slowing of reflexes, physical and emotional well-being (depression, helplessness), and safety awareness (reduced cognitive awareness).

Carol, a home healthcare nurse, is caring for a family from a low-income area. Four generations of the family live in this small, two-bedroom apartment, including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Lily, 28 years old; and Lily's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As Carol enters the home she visually scans the environment. Which observations are most concerning? Select all that apply. Several throw rugs on the floor A space heater on the floor Empty beer cans on the coffee table Open medication bottles next to the television A smoke detector hanging open in the kitchen

Several throw rugs on the floor A space heater on the floor Open medication bottles next to the television A smoke detector hanging open in the kitchen The use of throw rugs is common in many homes as a means to cover old flooring or add warmth to a cold floor. The rugs are a concern given William's age, because he is at a risk for falling. The space heater on the floor provides a risk for burns, especially for the children. The empty beer cans do not provide an immediate risk for safety but if they were partially full, they could pose a risk for the children. The open medication bottles are a risk for the children, and the nonfunctioning smoke detector is a risk for the entire family.

The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply. Trendelenburg Side-lying Head of bed flat Fetal position Head elevation

Side-lying Head elevation

An older adult client begins crying after being informed of her terminal illness. Which intervention by the nurse is best? Sit quietly with the client while she composes her thoughts. Inform the client that a chaplain is available if she would like to speak to one. Tell the client there are always options and suggest she not give up hope. Remind the client that she has lived a long and happy life.

Sit quietly with the client while she composes her thoughts.

Which nonverbal behavior best enhances communication? Keeping a neutral facial expression Maintaining a distance of 6 to 8 inches Sitting down to speak with the patient Asking open-ended questions

Sitting down to speak with the patient

Which healthcare team members are involved in hospice care? Select all that apply. Phlebotomists Social workers Dietitians Therapists Clergy

Social workers Therapists Clergy

Which precautions should the nurse take when giving a shot? Transmission Based (Tier 2) Handwashing only Standard (Tier 1)

Standard (Tier 1) The primary concern when giving a shot, starting an IV, or performing any other procedure using sharp objects is the prevention of blood transmission to the nurse. Standard precautions are used to minimize an incident.

What are some of the common problems of the mouth? Stomatitis halitosis Loose teeth Oral malignancies Cracked lips Dental Caries Gingivitis

Stomatitis halitosis Oral malignancies Cracked lips Dental Caries Gingivitis The most frequently seen mouth problems include dental caries and periodontal disease. Stomatitis (inflammation of the oral mucosa), halitosis (bad breath), oral malignancies (cancer), cracked lips (cheilosis), and gingivitis (inflammation of the gums) are common, whereas loose teeth are not.

Client: "You told me so much about my diabetes, I'm not sure I'll remember it." Nurse: "Don't worry, we'll give you everything in writing."Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Summarizing the conversation The client is interested in learning but was given too much information at one time. The nurse should summarize the conversation and create a teaching plan that allows for smaller amounts of information to be provided in each session.

The client has developed kidney and blood infection following a bladder infection from the urinary catheter. How would the nurse describe this infection? Select all that apply. Local Systemic Primary Secondary Healthcare related

Systemic Secondary Healthcare related

Which type of pain assessment tool rates pain on a scale of 0 to 10? The Wong-Baker FACES Pain Rating Scale The Numerical Rating Scale The Simple Descriptor Scale

The numerical rating scale The numerical rating scale uses the numbers 0 to 10 to rate the pain. A rating of "0" is no pain and a "10" is the worse pain possible. Patients choose a number from 0 to 10 to denote their pain level. This is the most commonly used pain scale for adults because it gives objective data for pain assessment comparisons.

Which is an example of a nurse who is using clinical judgment? The nurse collects the vital signs and auscultates the client's lungs, recording the data in the electronic record. The nurse is performing a procedure following a skill list that is in the policy and procedure manual. The nurse identifies some abnormal assessment findings and reports them to the next shift nurse during handoff report. The nurse identifies abnormal findings, investigates if the findings are new or old, and adjusts the plan of care accordingly.

The nurse identifies abnormal findings, investigates if the findings are new or old, and adjusts the plan of care accordingly.

Which statement is correct about critical thinking and the nursing process? The nursing process is a critical-thinking, problem-solving model. When using the nursing process, critical thinking is not needed. Everything a nurse does requires critical thinking. Nursing process is the only form of critical thinking used in nursing.

The nursing process is a critical-thinking, problem-solving model.

Pain intensity words (adjectives) are used to describe pain. Which type of pain scale is this? The Wong-Baker FACES Pain Rating Scale The Simple Descriptor Scale The Intensity Word Scale

The simple descriptor scale. The simple descriptor scale uses words such as mild, moderate, and severe to explain pain level. Nurses should use a few descriptive words to prevent confusion.

What type of pain scale consists of a horizontal line delineating "No pain" on one end and "Worst pain imaginable" on the other? The Visual Analog Scale The Numerical Rating Scale The Simple Descriptor Scale

The visual analog scale With the visual analog scale, a patient points to the location on the horizontal line that reflects their current pain level. It is simple and quick but can be confusing because of its abstract nature.

Which precaution should the nurse use when starting an IV for a client with a high fever and productive cough of unknown origin? Transmission Based (Tier 2) Handwashing only Standard (Tier 1)

Transmission based (Tier 2) When a client has signs of an unknown infection, it is safest for the nurse to implement transmission-based precautions. When the infection is localized to a wound or urine, contact precautions are sufficient. If the client is coughing, sneezing, or expectorating, the infection can be found on the droplets distributed throughout the room. In this case, droplet precautions are needed. Airborne precautions are utilized when the organism is small and known to exist in the air rather than on surfaces. Examples include tuberculosis, chickenpox, severe acute respiratory syndrome (SARS), and measles.

Client: "My neighbor just called and my dog died" (crying loudly). Nurse: "Tell me about your dog" (touching the client's shoulder). Which technique would improve the therapeutic communication? Active listening Establish trust Assertiveness Restating, clarifying, and validating messages Body language and sharing observations Exploring issues Using silence Summarizing the conversation

Using silence Loss is difficult for everyone. The nurse may not know what to say to help (and often there is nothing that can be said). Using silence would allow the client to grieve, feeling supported with the touch on the shoulder. Allow the client to speak when they are ready.

The nurse knows that falls most often occur in hospitals and long-term care facilities during which time frames? Select all that apply. Early mornings Midafternoons Weekends Nights Holidays

Weekends Nights Holidays

In which situation would standard precautions be adequate? Select all that apply. While talking with a client with a moist, productive cough While assisting a client with oral care While ambulating a client after a procedure While inserting an IV catheter When changing a dressing for a clients with MRSA

While assisting a client with oral care While ambulating a client after a procedure While inserting an IV catheter

Which statement about the nursing process is correct? Works alongside an individualized plan of care Results in outcomes designed by the client Is composed of a linear process with unique, distinct steps Includes only the care that the nurse will deliver

Works alongside an individualized plan of care