NUR 310 Exam 4

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? Wong-Baker FLACC Scale CRIES Pain Scale PAINAD Scale

CRIES Pain Scale

What factor has been hypothesized by researchers regarding current thoughts on sleep? Chronic sleep deprivation is present. The current population requires less sleep. More sleep is obtained through napping. The population is healthier due to sleep.

Chronic sleep deprivation is present.

The nurse is caring for a client with a diagnosis of insomnia who is returning to share the success of their sleep plan. Which statement by the client indicates that the plan was successful? Client identifies how many NREM cycles progressed through nightly. Client verbalizes feeling rested. Client can explain the direct actions of the hypnotic prescribed. Client describes the dreams experienced.

Client verbalizes feeling rested.

The client reports back pain and requests medication for the pain. The client is prescribed a placebo. The client believes an opioid is prescribed. What action will the nurse take? Ask another nurse what to do. Contact the health care provider. Administer the placebo. Inform the client.

Contact the health care provider.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? Cutaneous stimulation Biofeedback mechanism Patient-controlled analgesia (PCA) Guided imagery

Cutaneous stimulation

The nurse desiring to use laughter as a therapeutic modality for pain should assess for which therapeutic effects? Increased pain threshold Decreased heart rate Decreased levels of epinephrine Increased ability to face difficult procedure Shallow respirations

Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure

A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns? Limit food intake before bed. The spouse's sleeping pattern seems normal. Discuss the sleep pattern with the health care provider. Sleep in another room to limit your disruption of the spouse's sleep.

Discuss the sleep pattern with the health care provider.

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. You may smoke cigarettes during the day but not at night. Client is allowed to have one drink of alcohol each day. Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken. For better absorption, take your pain medication on an empty stomach.

Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken.

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern? How much sleep do you think you need to feel rested? In what way does the sleep you get each day affect your everyday living? What do you usually do to help yourself fall asleep? Do you usually go to bed and wake up about the same time each day?

Do you usually go to bed and wake up about the same time each day?

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate? Stop the back massage immediately. Massage the area using lotion. Apply a warm compress to the area. Document the finding.

Document the finding.

How should the nurse position the head of the bed for a client receiving epidural opioids? Reverse Trendelenburg Trendelenburg Elevated 30 degrees Flat

Elevated 30 degrees

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) Encourage deep breathing. Play the client's favorite music. Encourage the use of a sitter. Encourage increased protein. Promote a restful environment.

Encourage deep breathing. Play the client's favorite music. Promote a restful environment.

An older adult client reports insomnia. Which interventions can the nurse implement to promote quality sleep for the client? Advise the client to briskly ambulate in the hall for 60 minutes before bed. Encourage the client to empty the bladder at bedtime. Suggest that the client listen to music at bedtime to promote sleep. Keep lights on in the room to help prevent falls at night.

Encourage the client to empty the bladder at bedtime.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? Melatonin Serotonin Endorphins Dopamine

Endorphins

Which of the following is considered to be the most potent neuromodulators? Enkephalins Afferent Endorphins Efferent

Endorphins

An older adult client with mild hypothermia has been admitted to the health care facility. Which intervention will the nurse use to promote comfort and sleep for the older adult client? Raise the side rails of the bed. Use a bright light at night for safety. Keep an attendant with the client. Ensure that the environment is warmer.

Ensure that the environment is warmer.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? Educate the client/caregiver about signs of impending death Assess the client's serum albumin level Compare the client's current assessment with previous admission assessment Examine the effectiveness of the current pain regimen

Examine the effectiveness of the current pain regimen

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep? Find a phone app that plays sounds of the city. Avoid eating right before bedtime. Ingest 1 ounce of liquor before going to sleep. Enjoy the peace and quiet of the country.

Find a phone app that plays sounds of the city.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. For impaired physical mobility, perform ROM exercises every 2 hours. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For increased cardiac workload, instruct the client to lie in the prone position. For constipation, increase fluid intake and roughage. For ineffective breathing patterns, encourage shallow breathing and coughing.

For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? Fowler's Sims' prone supine

Fowler's

When asking an older adult client about abdominal pain, the client reports, "I do not want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action? Confirm that age is the reason for many types of pain. Gently mention that the client appears to be experiencing pain that can be treated. Remind the client that pain can be tolerated instead of using addictive pain medication. Document the client's statement, and do nothing further.

Gently mention that the client appears to be experiencing pain that can be treated.

Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents? Slow-wave sleep occurs less in toddlers than in adults. Most toddlers fall asleep easily. Nightmares are rare in toddlers. Getting the child to sleep can be difficult.

Getting the child to sleep can be difficult.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? Midbrain Cerebral cortex Medulla Hypothalamus

Hypothalamus

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Apply the stockings at night when the client is going to bed. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Avoid the use of powders on the legs before applying stockings. Apply the stockings after the client has been sitting up for an hour.

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include? Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. Inform parents about the preschool child's awareness of the concept of death possibly occurring and encourage parents to help alleviate the child's fears. Advise parents that waking from nightmares or night terrors is common during the adolescent stage. Teach parents of infants to report any eye movements, groaning, or grimacing by their infant during sleep periods.

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the health care provider for which intervention? Warm milk A hypnotic medication An opioid medication Low-flow oxygen

Low-flow oxygen

The nurse is preparing to educate a client with restless legs syndrome who reports sleeplessness and prefers to use nonpharmacologic methods to promote sleep. Which recommendation will the nurse include in the teaching? Massage the legs before bed. Sleep in a warm environment. Have a glass of wine before bed. Go to bed whenever you feel tired.

Massage the legs before bed.

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? Naloxone Atropine Diphenhydramine Epinephrine

Naloxone

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit? Naloxone Digoxin Furosemide Lisinopril

Naloxone

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns? Newborns will nap two times per day. Newborns are inactive when awake. Newborns sleep 16 to 17 hours per day. Newborns have shorter periods of REM sleep.

Newborns sleep 16 to 17 hours per day.

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? Opioid analgesics Nonopioid analgesics NSAIDs Corticosteroids

Opioid analgesics

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? one-time order standing order stat order PRN order

PRN order

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? A numeric scale should be used to assess pain if the child is older than 5 years of age. Pharmacologic pain relief should be used only as an intervention of last resort. The developing neurologic system of children transmits less pain than in older clients. Pain assessment may require multiple methods in order to ensure accurate pain data.

Pain assessment may require multiple methods in order to ensure accurate pain data.

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? Assessing for impaired urinary elimination Preventing constipation Observing for bowel incontinence Observing for diarrhea

Preventing constipation

A new client in the medical-surgical unit reports difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nurse identifies the nursing concern of altered sleep pattern with insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this this client's nursing concern? Use tactile relaxation techniques, such as a back massage. Provide an opportunity for the client to talk about concerns. Bring the client a warm glass of milk at bedtime. Help the client maintain normal bedtime routine and time for sleep.

Provide an opportunity for the client to talk about concerns.

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? Respiratory Cardiovascular Peripheral Vascular Neuromuscular

Respiratory

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? Privacy Safety Confidentiality Nurse-client relationship

Safety

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? Shift their weight back and forth, from back leg to front leg. Shift their weight back and forth from the legs to the back muscles. Rock the client back and forth to raise the client up in bed. Turn the client from side to side while pushing upward.

Shift their weight back and forth, from back leg to front leg.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? Fowler's supine Sims' prone

Sims'

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? Sims' prone Fowler's supine

Sims'

A nurse attempts to wake a sleeping client who is scheduled for tests. The client is easily aroused from sleep. Which stage of sleep is was this client most likely experiencing? Stage I Stage III Stage IV Stage II

Stage II

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? Administer analgesia 30 minutes before beginning a TENS session. Start with the lowest intensity and gradually increase it to the appropriate level. Disinfect with chlorhexidine the areas where the electrodes will be applied Turn on the unit shortly before applying the electrodes to the client's skin.

Start with the lowest intensity and gradually increase it to the appropriate level.

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? Stop the PCA pump. Administer naloxone. Notify the health care provider. Increase the primary IV rate.

Stop the PCA pump.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? The nurse should expect slight resistance during the removal of the epidural catheter. If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted.

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? The client obtains pain relief slowly and steadily. The client requires less nursing care. The client is actively involved in pain management. The client is able to have long hours of rest.

The client is actively involved in pain management.

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate? The worry will make the client fall asleep quickly. The client will likely sleep all night. The client will likely not be able to sleep. The client will probably not be able to stay asleep.

The client will likely not be able to sleep.

The nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique? The nurse gives the client a massage before bed. The nurse teaches the client deep-breathing techniques for relaxation. The nurse assists the client to focus on something pleasant rather than on pain. The nurse plays soft music in the client's room.

The nurse gives the client a massage before bed.

Using proper body mechanics, which motions would the nurse make to move an object? The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object.

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? This approach can only be used with oral analgesics. A PCA pump must be used and monitored in a health care facility. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. The PCA pump is not effective for chronic pain.

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

The nurse is assessing a client and determines that they are in rapid eye movement (REM) sleep. What finding indicates to the nurse that the client is in this stage? There is rapid eye movement under the eyelids. The individual is transitioning from wakefulness to sleep. Respirations are regular. There is muscle jerking that may awaken the individual.

There is rapid eye movement under the eyelids.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? Logrolling can be performed by one experienced nurse. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling will maintain straight alignment when the client is sitting in a chair. It is acceptable to twist the client's head, but not the hips, while logrolling.

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client? Administer opioid analgesics Use massage and heat application to the lower back Encourage the client to have an epidural steroid injection Have the client perform active exercises to stretch the back muscles

Use massage and heat application to the lower back

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply. Use the numeric rating scale. Observe the client. Use the Wong-Baker FACES pain rating scale. Ask the parents if the client is in pain. Ask the client to describe the pain.

Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? When lifting an object, I will keep my feet shoulder width apart. When lifting an object, I will bend at the knees instead of the waist. When I lift an object, I will get close to the object being lifted. When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? At several points throughout your history-taking When obtaining client vital signs The first question you ask the client Before the client is discharged

When obtaining client vital signs

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device? When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane. The client should hold the cane in the hand on the same side as the leg with the most severe deficit. The client should stand with as much weight as possible placed on the feet, using the cane for balance.

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

Which type of mobility aid would be most appropriate for a client who has poor balance? a cane with four prongs on the end (quad cane) a single-ended cane with a straight handle a single-ended cane with a half-circle handle axillary crutches

a cane with four prongs on the end (quad cane)

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include: an increase in stage II of the sleep cycle. a decrease in the deep sleep stage of the sleep cycle. a change in the normal progression of the sleep cycle. a decrease in stage I of the sleep cycle.

a decrease in the deep sleep stage of the sleep cycle.

A nurse is reviewing the medication administration record. Which order does the nurse question? a diuretic administered twice daily at 9 a.m. and 5 p.m. a diuretic administered once daily at 9 a.m. a diuretic administered twice daily at 9 a.m. and 9 p.m. a diuretic administered every other day at noon

a diuretic administered twice daily at 9 a.m. and 9 p.m.

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: assume the client does not need medication. ask the client's family if he ever uses pain medicines. document the client's lack of medication. actively solicit information about the client's pain level.

actively solicit information about the client's pain level.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid: adduction of the affected leg. extension of the knee on the affected leg. hip abduction. flexion of the knee on the affected leg.

adduction of the affected leg.

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects which primary nursing concern? altered role performance related to inability to work at occupation anxiety related to hospitalization altered physical mobility related to restless leg syndrome altered sleep pattern related to acute pain

altered sleep pattern related to acute pain

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to: apply a facial mask that will deliver positive air pressure. anticipate sleeping overnight at a health care center. insert an oral appliance prior to attempting sleep. take a prescribed sedative before trying to sleep.

anticipate sleeping overnight at a health care center.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? bed trapeze foot board trochanter roll bed cradle

bed trapeze

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: Therapeutic Touch (TT). hypnosis. biofeedback. transcutaneous electrical nerve stimulation (TENS).

biofeedback.

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? rates pain an 8 on a 0 to 10 scale B/P 178/92 and pulse 118 confused to time and place right shoulder immobilizer in place

confused to time and place

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? positioning the client on the stomach contacting the primary health care provider placing a small towel under the neck administering a muscle relaxer

contacting the primary health care provider

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? reports of pain in the lower back unequal pupil size stumbling gait decrease in flexibility

decrease in flexibility

What is a benefit of regular exercise over time? increased risk for blood clots decreased heart rate decreased venous return increased work of breathing

decreased heart rate

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. substance use glaucoma depression constipation stroke type 1 diabetes mellitus

depression substance use constipation stroke

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply. decreased blood pressure elevated heart rate pallor (peripheral vasoconstriction) decreased temperature elevated respiratory rate

elevated respiratory rate decreased blood pressure

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: decubitus ulcers. pooling of blood. foot drop. blood pressure changes.

foot drop.

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? lorazepam morphine gabapentin hydromorphone

gabapentin

When moving a client up in bed with the assistance of another caregiver, the nurse should: elevate the head of the bed. ask another nurse about the plan of care. maintain a pillow under the client's head. have the client fold the arms across the chest.

have the client fold the arms across the chest.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client: experiencing acute pain. in the postoperative stage with occasional pain. experiencing chronic pain. in the early postoperative period.

in the postoperative stage with occasional pain.

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? increased blood pressure pupil constriction decreased respiratory rate decreased pulse rate

increased blood pressure

A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)? Select all that apply. fainting or unconsciousness cool, moist skin increased respiratory rate increased pulse increased blood pressure

increased pulse increased respiratory rate increased blood pressure

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? requires a better walking shoe. requires crutches for mobility. should have an orthopedic consultation. is demonstrating a common gait for the older adult.

is demonstrating a common gait for the older adult.

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? requires crutches for mobility. is demonstrating a common gait for the older adult. requires a better walking shoe. should have an orthopedic consultation.

is demonstrating a common gait for the older adult.

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? leg chest arm back

leg

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? pull the client to the edge of the bed to which the client will be turning push the client to the edge of the bed to which the client will be turning push the client to the opposite side of the bed move the client to edge of the bed opposite the side that client will be turning

move the client to edge of the bed opposite the side that client will be turning

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed near the client's hip, with legs together to the nondominant side of the client, with legs together and one foot near the head of the bed.

near the client's hip, with legs shoulder width apart and one foot near the head of the bed

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client? deep vein thrombosis orthostatic hypotension hypertension circulatory alterations

orthostatic hypotension

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? positioning a friction-reducing sheet under the client to facilitate movement using back muscles to gently and gradually pull the client to the side placing the bed in its lowest position to reduce the client's risk for falls standing at the top of the bed and having a colleague stand at the bottom of the bed

positioning a friction-reducing sheet under the client to facilitate movement

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in circulating fibrinolysin increase in the movement of secretions in the respiratory tract predisposition to renal calculi increased metabolic rate

predisposition to renal calculi

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity? cover the client with the bed linens assess for pain place the call bell within reach pull the shoulder blade forward and out from under the client

pull the shoulder blade forward and out from under the client

In Stage 4 sleep, the: respirations are irregular pulse rate is slow blood pressure is elevated temperature increases

pulse rate is slow

Which factor necessitates the need for more sleep in the adolescent population? increased nutritional needs rapid growth increased life stresses part-time employment

rapid growth

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. installing hardwood floors removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? reviewing and revising the pain management treatment plan judging whether the client is in pain or is just depressed beginning pain medications before the pain is too severe administering a placebo and performing a reassessment of the pain

reviewing and revising the pain management treatment plan

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is: reviewing the client's sleep diary for the past 2 weeks. identifying specific foods that negatively impact sleep. asking the client's bed partner to describe the sleep problem. having the client recall the number of sleep hours each night for the past week.

reviewing the client's sleep diary for the past 2 weeks.

A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use? anxiety sedation insomnia diarrhea

sedation

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns? hypnogogic hallucinations and sleep paralysis sleep paralysis and automatic behavior sleep paralysis and hypnogogic hallucinations cataplexy and hypnogogic hallucinations

sleep paralysis and automatic behavior

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply. smokes 1 pack of cigarettes daily works 30 hours per week exercises 30 to 60 minutes daily drinks coffee with all meals history of hyperthyroidism

smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism

The nurse is caring for a client who must receive medication overnight. As the nurse prepares to administer the medication, the client is noted to have relaxed muscle tone, is not moving, snores, and is difficult to arouse. How will the nurse document this stage of sleep? REM stage 3 stage 2 NREM

stage 3

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: uses the sides of the walker to rise from a chair. places the walker far in front when walking. leans over the walker when walking. steps into the walker when walking.

steps into the walker when walking.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? prone lateral supine Sims'

supine

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's head supporting the client's back in front of the client's abdomen under the client's feet

supporting the client's back

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? the 3-month-old child who is unable to raise the head when prone the 18-month-old child who is unable to stack blocks the 24-month-old child who is unable to walk unassisted the 6-month-old child who is unable to roll over

the 24-month-old child who is unable to walk unassisted

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain? the client's recent responses to pain and to pain medication the nurse's impression of the client's pain the client's pain based on a pain rating nonverbal cues of the client

the client's pain based on a pain rating

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because: they are the age group least likely to use prescribed sleep medications. they are typically prone to sleep walking. they may be disoriented on awakening. they nap in the afternoon, which lessens their hours of sleep at night.

they may be disoriented on awakening.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? pooling of secretions oliguria thrombus formation skeletal contractures

thrombus formation

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? thrombus formation skeletal contractures oliguria pooling of secretions

thrombus formation

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? roller sheet transfer belt mechanical lift transfer boards

transfer belt

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care? pull sheets trapeze bar trochanter rolls log rolling

trapeze bar

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? foot splints roller sheets foot boards trochanter rolls

trochanter rolls

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to: use caution when driving an automobile. ingest a small amount of alcohol prior to bedtime. change bedtime to later in the evening. drink at least 1 cup of coffee with the evening meal.

use caution when driving an automobile

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision? verbal report nonverbal clues increased respiratory rate generalized increase in metabolism

verbal report

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: cutaneous pain. somatic pain. visceral pain. neuropathic pain.

visceral pain.

A school nurse is speaking to a group of parents regarding the sleep needs of adolescents. Which statement by a parent indicates a need for further education? "Adolescents naturally develop an owl-like sleep pattern in which they go to bed later and sleep later in the morning." "Academic performance in adolescents is good when they sleep about 7 hours per night." "Adolescents catch up on sleep on the weekends, when they typically sleep later." "Adolescent girls are more likely to develop insomnia than boys."

"Academic performance in adolescents is good when they sleep about 7 hours per night."

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as "You will need more pain medication as the days progress." "Your present pain is worse because you had your packing removed." "I will call your doctor because you may have loosened sutures when walking." "Acute pain tends to increase during the day and is called a routine pain response"

"Acute pain tends to increase during the day and is called a routine pain response"

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? "When did your pain begin?" "Can you describe the type of pain you are having?" "How long have you experienced this pain?" "Could you please rate your pain on a 1-10 scale?"

"Can you describe the type of pain you are having?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? "Wearing the TENS unit should not interfere with my daily activities." "One advantage of the TENS unit is it increases blood flow." "I may need fewer pain medications with the TENS unit in place." "I could use the TENS unit if I feel pain somewhere else on my body."

"I could use the TENS unit if I feel pain somewhere else on my body."

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting? "I stand with my feet apart so I have a better stance when I lift." "I hold the boxes away from my body so I do not drop them on my feet." "I bend with my knees when I pick up boxes." "I try to rest between periods of lifting."

"I hold the boxes away from my body so I do not drop them on my feet."

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary? "I will only keep track of my sleep habits at home, not when I am traveling out of town." "I will write down all my morning activities." "I will keep track of my sleep information for 2 months." "I will record the time I go to bed and how long it takes me to fall asleep."

"I will record the time I go to bed and how long it takes me to fall asleep."

A hospitalized client informs the evening shift nurse about not being able to sleep without a shot of whiskey each night before bed and asks if the spouse can bring in a bottle. Which is the best response by the nurse? "Let's discuss that with your health care provider." "Do you really think that is a good habit?" "Go ahead and ask your spouse to bring a bottle." "It will be difficult for you to continue that routine in the hospital."

"Let's discuss that with your health care provider."

A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse? "Try to stay awake for the duration of the flight and sleep when you arrive." "You should take sleeping pills when you board so that you will sleep until you arrive at your destination. "If you have jet lag once, you shouldn't have any further problems on your next trip overseas." "Light therapy can be beneficial and help ease the transition to a new time schedule or zone."

"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? "Don't put on your shoes yet." "Put on your shirt." "Put your pants on and zip the zipper." "Put your arm in this sleeve."

"Put your arm in this sleeve."

A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. "Your elbows should be nearly straight when you grasp the walker." "Stand centered between the back legs of the walker." "Line up the top of the walker with the crease on the inside of your wrist." "Keep your arms relaxed at the side of the walker." "Move the walker forward 12 to 18 in (30 to 45 cm) with each step and set it down."

"Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist."

Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate? "Have you ever had pain like this before?" "Tell me where your pain is located." "Do you need your pain medication now?" "Tell me more about your pain."

"Tell me more about your pain."

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement? "I cannot recall when this pain started." "I am experiencing a very low mood right now." "No amount of medication seems to relieve the pain completely." "The pain is really sharp in this one spot."

"The pain is really sharp in this one spot."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? "If you feel severe pain, either push the button yourself or ask one of your family members to push the button." "The pump is programmed with safeguards to limit the possibility overmedication." "I'll have the unit's care aide come check on you every few minutes after I set up the system." "We'll be monitoring your use of the system closely, to ensure you don't develop an addiction to your pain medication."

"The pump is programmed with safeguards to limit the possibility overmedication."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent the legs from rotating outward." "To help client to turn independently." "To prevent foot drop."

"To preserve the client's functional ability to grasp and pick up objects."

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To avoid contractures." "To prevent foot drop." "To preserve your functional ability to grasp and pick up objects." "To prevent your legs from rotating outward."

"To prevent your legs from rotating outward."

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? "If you recently fell, you might have a fractured hip." "Because you lose muscle tone with age, it hurts to walk." "Osteoarthritis is painful and very common as you age." "You have lost the padding in your joints and the friction causes pain."

"You have lost the padding in your joints and the friction causes pain."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "We will have the unlicensed assistive personnel watch you while you walk around the unit the first time." "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." "Your elbows will be slightly bent when you are using your crutches." "When your crutches fit right, most of your body weight will be supported by your armpits."

"Your elbows will be slightly bent when you are using your crutches."

A nurse is assessing an adult client with back pain. The client is unable to speak the dominant language. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? FLACC scale 0 to 10 numeric rating scale PAINAD scale Payen behavioral pain scale

0 to 10 numeric rating scale

The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours in a 24 hour period? 14 to 18 hours 10 to 12 hours 18 to 20 hours 8 to 10 hours

14 to 18 hours

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? A client with chest pain who is having a myocardial infarction A client suspected to have a perforated peptic ulcer A client who has a sprained ankle A client who has appendicitis

A client who has a sprained ankle

Which medical client is most likely to be experiencing diffuse pain? A client with shingles affecting her entire torso A client who has been prescribed antibiotics for the treatment of strep throat A client who has presented to the emergency department with a stab wound A client who is undergoing diagnostic testing for appendicitis

A client with shingles affecting her entire torso

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response? Stimulates the reticular activating system Activates the receptors for the hormone melatonin Causes a change in the circadian rhythms Decreases impulses to the cerebral cortex

Activates the receptors for the hormone melatonin

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Circumduction Extension Abduction Adduction

Adduction

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? Reassess the client's pain in 30 minutes. Hold the pain medication. Administer the pain medication. Contact the client's health care provider.

Administer the pain medication.

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse? Begin CPR Administration of 0.4 mg of naloxone Place the client in the supine position Administer a lower dose of the analgesic for the next dose

Administration of 0.4 mg of naloxone

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation? Distract the boy so he does not notice his pain. Medicate the boy with analgesics to reduce the anxiety of experiencing pain. Ignore the boy's pain if he is not complaining about it. Ask the boy to draw a cartoon about the color or shape of his pain.

Ask the boy to draw a cartoon about the color or shape of his pain.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention? Tell the healthcare provider that the client is unsure of the pain medication taken. Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. Document what the client states. Call the pharmacy to attempt to identify the pill.

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain? Compare the client's presentation to expected outcomes at this point in recovery. Correlate the client's vital signs with their symptoms. Assess and document the client's behaviors over a period of hours. Ask the client to describe and rate their pain.

Ask the client to describe and rate their pain.

The nurse prepares to promote the client's comfort using guided imagery. Which actions should the nurse take? Select all that apply. Ask the client to imagine oneself in a favorite place. Ask the client to concentrate on the details of a pleasant image. Play the client's favorite music in the background. Instruct the client how to breathe properly for relaxation. Read a book to the client who is postoperative. Ask the client to focus on tightening and relaxing a particular muscle group.

Ask the client to imagine oneself in a favorite place. Ask the client to concentrate on the details of a pleasant image.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. Assess for pain control 30 minutes after administering an analgesic. Delegate pain assessment to the UAP. Infer that the client who does not complain has no pain. Provide pain medication before activity that may increase pain. Consider cultural implications of the perception of pain.

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? Ask a peer to come and observe the sleep pattern. Call a code blue, as the client is not breathing. Review the client's medical record for sleep disturbances. Assess the client's vital signs and pulse oximetry.

Assess the client's vital signs and pulse oximetry.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement? Assess the factors that the client believes contribute to the problem. Educate the client on relaxation techniques and reduce noise levels on the unit. Facilitate a change in the client's diet to ensure more carbohydrates at dinner. Obtain a PRN order for a sedative hypnotic from the client's health care provider.

Assess the factors that the client believes contribute to the problem.

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? Gently massage the region, document the finding, and verbally report it to the health care provider. Avoid massaging the area and apply a thin layer of a topical antibiotic ointment. Avoid massaging this area and report the finding to the health care provider. Massage the area in an attempt to restore adequate circulation.

Avoid massaging this area and report the finding to the health care provider.