Nurs 202 Final

A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) (hint only 2) a. stage 3 pressure injury b. Casted bone fracture c. Open burn area d. Sutured surgical incision e. Laceration sealed with adhesive

A & C

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client every 3 hr while in bed.

A & D

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: A. A 19 year old female who is a quadriplegic. B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. C. A 55 year old female who has controlled diabetes and is ambulating three times a day. D. A 76 year old male with an elevated ammonia level and is excessively sweaty. E. A 45 year old with a Braden Scale score of 7.

A, B, D, and E

A nurse is caring for a client who has terminal lung cancer. Match The client statements to the Kubler-Ross model stage of grief the client is experiencing: A. "I am looking forward to our family reunion next year." B. "This is so unfair. Why is this happening to me?" C. "I promise to go to church every day, if I live through this." D. "I have nothing to live for anyway." E. "I have lived a good life."

A. Denial B. Anger C. Bargaining D. Depression E. Acceptance

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. Presence of associated manifestations

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A: "A nurse will show me how to care for my wound" B: "A nurse will stay with me at home during the day" C: "I will call the nurse to change my bed linens" D: "I will call the nurse to help me bathe in the morning"

A: "A nurse will show me how to care for my wound"

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A: Aspiration of water B: Infection of the stoma C: Bleeding around the stoma D: Skin breakdown around the stoma

A: Aspiration of water

A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A: Initiate range-of-motion exercises B: Use clean technique to provide wound care C: Place the client on a low-protein diet D: Maintain the client on bed rest

A: Initiate range-of-motion exercises (Begin active and passive ROM exercises to maintain mobility and prevent contractures)

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infections, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A: Vitamin C and Zinc B: Vitamin D C: Vitamin K and Iron D: Calcium

A: Vitamin C and Zinc (Both promote skin and wound healing)

Routine Clinical Approach to Pain Assessment and Management (ABCDE)

Ask Believe Choose Deliver Empower

A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply) A: Use cotton balls to clean the infected areas B: Cleanse the wound with tap water C: Dry the leg wound after cleaning D: Microwave the cleaning solution before applying to the wound E: Discard soiled bandages in a moisture-proof bag

B & E (Tap water or 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags to prevent spread of contamination.)

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position? (Select all that apply) A. Sacral B. Patella C. Ankle D. Ear E. Elbow F. Hip G. Heel H. Shoulder

B, C, D, F, and H (The right lateral recumbent position is where the patient is positioned on their right side.)

You're developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. The patient is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all the nursing interventions you will include in the patient's plan of care to prevent a pressure injury: A. When feeding the patient keep the head of bed elevated at 45′ degree and avoid elevating the foot of the bed. B. Apply barrier cream as needed to the skin daily. C. Turn the patient every 4 hours. D. Keep linens and gowns dry and wrinkle free. E. Use a wedge pillow for the right and left legs daily.

B, D, and E

The nurse is performing an assessment of the patient's thorax and lungs. In which order will the nurse perform the following assessment techniques? 1. Percussion, 2. Auscultation, 3. Inspection, 4. Palpation A.3, 1, 4, 2 B. 3, 4, 1, 2 C.2, 4, 3, 1 D.2, 3, 4, 1 E.3, 2, 4, 1

B. 3, 4, 1, 2

While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be? A. Stage 1 pressure injury B. Deep-tissue injury C. Stage 4 pressure injury D. Stage 2 pressure injury

B. Deep-tissue injury (Deep-tissue injuries presents as purplish or blackish areas over skin that is intact.)

You receive report that your patient who will be admitted to your unit has a stage 4 pressure injury. Which figure above represents this type of injury? A. Figure 1 B. Figure 2 C. Figure 3 D. Figure 4

B. Figure 2

A nurse learns that a coworker has died unexpectedly. Which of the following actions should the nurse take? A. Keep personal feelings of grief to themselves B. Recognize their feelings of grief C. Attempt to ignore physical manifestations of grief D. Avoid family and friends when feeling deep sadness

B. Recognize their feelings of grief

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A: "I'll wrap the old dressing in a paper bag and put it in the trash" B: "I'll wash my hands before I remove the old dressing and again before putting on the new one" C: "I'll need to take a pain pill 30 minutes before I change the dressing" D: "I'll wear sterile gloves when I apply the new dressing"

B: "I'll wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters? A: Blood glucose B: Blood pressure C: Daily weight D: Sensation in the feet

B: Blood pressure (A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function)

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A: Preventing the transfer of microorganisms to the nurse B: Keeping microorganisms from entering the wound C: Applying minimal pressure to the wound D: Keeping excess moisture from entering the wound

B: Keeping microorganisms from entering the wound

A nurse is assigned to care for several clients who are postoperative. The client taking which of the following medications is at risk of delayed wound healing? A: Nifedipine to treat hypertension B: Prednisone to treat persistent arthritis exacerbations C: Albuterol to treat asthma D: Chlorpromazine to treat schizophrenia

B: Prednisone to treat persistent arthritis exacerbations (It's a corticosteroid associated with delayed wound healing)

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend? A: Spiritual advisor B: Social worker C: Physical therapist D: Occupational therapist

B: Social worker

A nurse is caring for a 45-year-old client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply A. Age B. Low Hemoglobin C. Malnutrition D. Chronic Illness E. Poor wound care

C, B, D,

A nurse is caring for a client who is expected to die within 24 hours. The client's family asks the nurse what physical changes to expect. Which manifestations should the nurse include? (select all that apply) A. Increased urine output B. Warm extremities C. Decreased muscle tone D. Periods of apnea E. Bowel incontinence

C, D, E

A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take? (select all that apply) A. Make sure the body is lying completely flat B. Remove dentures from the client C. Place a clean gown on the client's body D. Remove all equipment from the client's bedside E. Dim the lights in the client's room.

C, D, E

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon. B. A hallmark of a stage 3 pressure injury is that the skin will be intact but it not blanch. C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue. D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury.

C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A: Obtain the prescribed irrigation solution B: Don personal protective equipment C: Check the client's pain level D: Place a waterproof pad under the client's extremity

C: Check the client's pain level

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client? A: Make eye contact with the interpreter B: Break sentences into shorter segments to allow time for interpretation C: Ensure the interpreter and the client speak the same dialect D: Speak in a loud tone of voice

C: Ensure the interpreter and the client speak the same dialect

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using the scale, which of the following parameters should the nurse evaluate? A: Incontinence B: Mental state C: Nutrition D: General physical condition

C: Nutrition (Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters of the Braden scale)

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A: Famotidine B: Esomeprazole C: Vasopressin D: Omeprazole

C: Vasopressin (It constricts the splanchnic bed and decreases portal pressure. It also constricts the distal esophageal and proximal gastric veins, which reduce inflow into the portal system and is used to treat bleeding varices)

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) Hint- only 2 a. Use sterile gauze to apply gentle pressure to the exposed tissues. b. Apply an abdominal binder snugly around the abdomen. c. Offer the client a warm beverage (herbal tea). d. Position the client supine with the hips and knees bent. e. Cover the area with saline-soaked sterile dressings.

D & E

A nurse is assessing a 16-year-old client whose parent recently died. Which of the following findings should the nurse expect? A. The client is still developing an understanding of death B. the client feels that "everyone understand me" C. The client can easily express their emotions D. The client displays high-risk behaviors

D. The nurse should identify that a 16 yo whose parent has recently died might display high risk behaviors

How would you as the nurse stage figure 3: A. Stage 1 B. Stage 3 C. Stage 2 D. Unstageable E. Stage 4

D. Unstageable (Note the slough and eschar in the wound bed. As the nurse you are unable to assess the depth of the wound)

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A: "Move between the bed and wheelchair once every 2 hours" B: "Make sure that your caregiver massages your skin daily" C: "Use a rubber ring when sitting on the bedside" D: "Shift your weight in the wheelchair every 15 minutes"

D: "Shift your weight in the wheelchair every 15 minutes"

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? A: "You will need to apply a cold pack to the site 3 times a day" B: "Your provider might as you to walk frequently to increase circulation to the area" C: "You will need to limit your consumption of high-protein goods" D: "Your provider might prescribe a central catheter line for long-term antibiotic therapy"

D: "Your provider might prescribe a central catheter line for long-term antibiotic therapy" (It's an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment)

A Nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A: Insufficient skin care B: Dehydration C: Immobility D: Impaired circulation

D: Impaired circulation (Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes)

You have a new admission. While performing a head-to-toe assessment on your patient, you note the following wound on the patient's right heel. You document this as a: A. Stage 1 Pressure Injury B. Stage 3 Pressure Injury C. Unstageable D. Deep-Tissue Injury E. Stage 2 Pressure Injury F. Stage 4 Pressure Injury

E. Stage 2 Pressure Injury (The skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) is visible. These wounds may be opened with a superficial red/pink ulcer or may have the formation of an opened or closed blister.)

Nursing Assessment Questions for Pain Mgmt (PQRRSTU)

P: Palliative or Provocative factors Q: Quality R: Relief measures R: Region (location) S: Severity T: Timing U: Effect of pain

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting the client with all ADLs. What rationale for self-care should the nurse communicate with the family?

When taking actions the nurse should communicate to the client's family that they should allow the client to perform their own ADLs as much as possible to maintain dignity, control, and self-esteem.

A nurse is consoling the partner of a client who just died after a long battle with cancer. The grieving partner states, " I hate them for leaving me." What actions should the nurse take to facilitate mourning for the client's partner?

When taking actions, the nurse should assist the client's partner through the mourning process by using therapeutic communication to encourage the partner to express their feelings. The nurse should ask the client's partner whether they would like to talk to a spiritual leader to provide spiritual support and guidance. The nurse should provide education to the grieving individual about the grieving process and about emotions they can expect at this time to assist the client's partner through the mourning process.

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply) a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst

a, b, c

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism b. A patient with coronary artery disease c. A patient who has gastroesophageal reflux (GERD) d. A patient who is HIV positive e. A patient who is taking corticosteroids for arthritis f. A patient with a urinary tract infection

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

A nurse formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining state of Kubler-Ross's stages of grief? a. "I would give anything to live to see my grandchild born" b. "Can you make sure there hasn't been a mistake with my test results?" c. "I feel so sad that I will be leaving my partner all alone" d. "What have I done to deserve this death sentence?"

a. "I would give anything to live to see my grandchild born"

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? a. Stage I NREM sleep b. Stage II NREM sleep c. Stage IV NREM sleep d. REM sleep

a. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility.

To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.

a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? a. the death was a result of violence b. the client expresses anger over the loss c. this is the client's first experience of the loss of a family member d. the client demonstrated reorganization of behavior

a. the death was a result of violence

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia b. A patient with Parkinson disease who is taking dopamine c. An elderly patient taking diuretics for congestive heart failure d. A patient who is taking antibiotics for an ear infection e. A patient who is prescribed antidepressants f. A patient who is taking low-dose aspirin prophylactically

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

A nurse is providing support for a client who is grieving the loss of her mother who died from Alzheimer's disease. Which of the following statements should the nurse make? a. "I know how you're feeling. I recently lost my father. " b. "It must be very difficult for you to deal with your mother's death." c. "Hopefully, knowing your mother is in a better place provides you with some comfort." d. "I want you to let me know what I can do to help you cope with your mother's death."

b. "It must be very difficult for you to deal with your mother's death."

A nurse assesses a patient's body temperature in the late afternoon as 37.2°C (99°F). What would be the nurse's best action related to this slight elevation in temperature? a. Assess the patient for infection. b. Record the temperature as a normal finding. c. Call the physician for an order for antipyretics. d. Decrease the room temperature.

b. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. REM behavior disorder b. Narcolepsy c. Enuresis d. Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c .Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

The pain management nurse assesses a trauma patient's readiness for discharge by determining the level of comfort the patient prefers. The nurse completes this portion of the pain assessment by asking about the patient's: a. aggravating and alleviating factors. b. functional pain goal. c. intensity of pain. d. onset of pain.

b. functional pain goal.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c. It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep.f. The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which o the following statements indicates that the client knows how to use the device? a. "I'll wait to use the device until its absolutely necessary" b. "I'll be careful about pushing the button too much so I don't get an overdose" c. "I should tell the nurse if the pain doesn't stop while I am using this device" d. "I will ask my adult child to push the dose button when I am sleeping "

c. "I should tell the nurse if the pain doesn't stop while I am using this device"

A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.

c. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increases both REM and NREM sleep.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? a. Ineffective Coping: Multiple Stressors of New Job b. Sleep Deprivation: Difficulty Falling Asleep c. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern d. Risk for Injury: Activity Intolerance/Sleep Deprivation

c. When assessment data point to a sleep problem that is amenable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined.

A nurse in an assisted living facility is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief? a. anticipatory grief b. delayed grief c. acute grief d. disenfranchised grief

c. acute grief

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply) a. urinary incontinence b. diarrhea c. bradypnea d. orthostatic hypotension e. nausea

c. bradypnea d. orthostatic hypotension e. nausea

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client? a. bargaining b. acceptance c. denial d. anger

c. denial

A nurse is assessing a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? a. ask the client what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure the pain d. use open-ended questions to identify the client's pain sensations

c. offer the client a pain scale to measure the pain

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? a. the deceased was a close friend. b. the client lived far from the deceased. c. the death was sudden d. the client has not visited the deceased in a long time

c. the death was sudden

A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks

A 45-year-old patient who reports pain in the foot that moves up along the calf says, "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and they have no prior history of injury or falls. Which components of pain assessment has the patient reported? a. Aggravating and alleviating factors. b. Exacerbation, with associated signs and symptoms. c. Intensity, temporal characteristics, and functional impact. d. Location, quality, and duration.

d. Location, quality, and duration.

A nurse working the night shift in a pediatric unit observes a 10-year-old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? a. Bruxism b. Cataplexy c. Restless leg syndrome d. Somnambulism

d. Somnambulism (sleepwalking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding of one's teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72hrs following pacemaker insertion c. a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall 2 years ago

d. a client who has episodic back pain following a fall 2 years ago

The main responsibilities of the pain management nurse on the interprofessional, chronic pain management team are to: a. assess the level of function; design a therapeutic exercise plan; and monitor functional progress. b. provide a comprehensive, psychosocial evaluation; implement cognitive behavioral interventions; and teach problem-solving techniques. c. provide ergonomic training; develop pain management strategies to apply in the workplace; and facilitate the return to work. d. review the medical history; monitor medications; and provide education for the patient and family.

d. review the medical history; monitor medications; and provide education for the patient and family.

5 Stages of grief

denial, anger, bargaining, depression, acceptance