10/25/22 Exam 3 study

The nursing instructor wants to evaluate the student's knowledge of sensory functioning. The instructor knows the student understands sensory reception when the student states which of the following?

"Stereognosis is the sense that perceives the solidity of objects."

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

A= Assessment

Which statement accurately describes a developmental consideration when assessing skin integrity of clients?

An infant's skin and mucous membranes are injured easily and are subject to infection.

An older adult client has been hospitalized for 8 days following skin grafting. The nurse suspects the client is experiencing sensory deprivation. Which strategy will be most effective in this situation?

Assess and reorient the client to time, place, and person as needed.

The health care provider tells the nurse that the older adult client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

Delusions

A student nurse is preparing a presentation on sensory overload. What symptoms of sensory overload should the student include? Select all that apply.

Disorientation Sleeplessness Confusion Fatigue

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.

Pain with redness and swelling Localized heat Purulent or malodorous drainage

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

Perception

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of pressure injuries. What is the name given to the factor responsible for this risk?

Shearing force

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage 2

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.

The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU?

Use limited light

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

a client 68 years of age who is bedfast related to severe head trauma

The process of phagocytosis involves: depletion of serotonin in the brain cells. digestion of microbes by white blood cells. secretion of a nonspecific chemical inhibitor. breakdown of proteins into amino acids.

digestion of microbes by white blood cells

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?

immediately deposit uncapped needles into a puncture-proof plastic container

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his:

reticular activating system (RAS).

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention

A client tells the nurse that they have difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition?

sensory deficit

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous

People receive data to experience the world. What are conditions that must be met for this to occur? Select all that apply.

A stimulus, such as an agent, act, or other influence, must be present. A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. The nerve impulse must be conducted along a pathway from the receptor or sense organ to the brain. A particular area in the brain must receive and translate the impulse into a sensation.

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound.

What are functions of the skin? Select all that apply.

Protection Temperature regulation Sensation Immunologic

A client admitted to the hospital for major surgery is at risk for what type of sensory alteration?

Sensory overload

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration

To eliminate needlesticks as potential hazards to nurses, the nurse should:

immediately deposit uncapped needles into a puncture-proof plastic container

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

increased respiratory rate lymph node enlargement fever

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:

prodromal period

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care