NSG 3600 Exam 4
A client with asthma tries to jog a mile but cannot finish and complains of fatigue. An appropriate nursing diagnosis would be
Activity intolerance related to fatigue.
The nurse knows that effective communication with children and their parents is critical to providing atraumatic quality nursing care. Which of the following statements accurately describes the communication patterns of children?
Children rely more on nonverbal communication and silence. Children often use fewer words than adults and may rely more on nonverbal communication and silence. Communication patterns can vary greatly from one child to the next. Some children are very talkative, while others are quiet. Parents more often require neutral communication (i.e., verbal communication that is related to assessing and solving problems), whereas children more often desire affective communication (establishment of rapport and trust, giving comfort).
When assessing an elderly client's home for safety, the nurse should recommend
Eliminating throw rugs
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?
Axillary method
The nurse is explaining the difference between active and passive immunity to the student nurse. Which of the following statements accurately describes a characteristic of the process of immunity?
Passive immunity can be obtained by injection of exogenous immunoglobulins.
A female patient asks the nurse why she urinates more frequently as she is getting older. Which of the following is the nurse's best response?
"Your bladder capacity decreases with age."
You are the nurse caring for an elderly patient who is confused and agitated. When the patients' family comes to visit the patient you ask them how long the patient has been confused. The family states that the patient has been confused for a long time and the confusion is getting worse. The patient is subsequently diagnosed with dementia. What is the most common cause of dementia in an elderly patient?
Alzheimer's disease.
The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?
Decrease anxiety and fear during hospitalization and painful procedures. The CLS is a specially trained individual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful. The goal of the CLS is to decrease the anxiety and fear while improving and encouraging understanding and cooperation of the child. The CLS may use distraction techniques and act as a liaison, but that is not the primary goal of the CLS role. The CLS does not perform medical procedures
An 84-year-old patient has returned from the PACU. The patient is orientated to name only. The patients' family is very upset because before having surgery the patient knew the family. The patient is diagnosed with delirium. What should the nurse explain to the patient's family?
Delirium usually lasts only a short time.
When the home care nurse visits a 78-year-old female patient who is recently widowed and finds that the home is cluttered with trash and the patient appears sad and disheveled, the nurse should assess the patient for symptoms of
Depression
The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question?
Endocrine Indicators of problems with the endocrine system include increased thirst, excessive appetite, delayed or early pubertal changes, and problems with growth. For the genitourinary system the nurse would assess urinary patterns and genitals. For the hematologic system the nurse would assess lymph nodes, skin color, and bruising. Signs of neurologic problems include numbness, tingling, difficulty learning, altered mood or ability to stay alert, tremors, tics, and seizures
A home healthcare nurse has observed that an 80-year-old patient who has multiple chronic health problems takes a total of 19 medications on either a scheduled or PRN (as needed) basis. How should the nurse address this patient's risk of harm from polypharmacy?
Ensure that the patient's care is coordinated and encourage the primary care provider to review her medication regimen.
A nurse uses proper body mechanics to move a patient up in bed. Which of the following is a guideline for using these techniques properly?
Face the direction of movement.
An elderly patient informs the nurse, "I just don't feel like myself. I cry so easily and my mobility is so bad from my degenerative disc disease in my back." What factor is most likely contributing to the patient's depression?
Pain Many factors place an older adult at risk for depression, including recent bereavement, a change in environment, alcohol or substance use, and chronic pain.
The nurse is administering a hepatitis B vaccine to a child. What is the classification of this type of vaccine?
Recombinant vaccines
The nurse is preparing to put a patient's joints through the range of motion. What guideline will the nurse consider when performing the range of motion?
Return the joint to a neutral position when finishing each exercise. Guidelines to follow when performing range of motion include returning the joint to a neutral position when finishing each exercise. The nurse should not perform range-of-motion exercises until the patient is fatigued because the exercises are not to exhaust or tax the individual. Avoid attempts to achieve full range of motion in older adults because these movements may be painful. All movements should be smooth and rhythmic.
The nurse is assisting a patient to ambulate following knee surgery. What is a key concern when assisting patients with activity?
Safety.
A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?
Spreading feet shoulder-width apart to broaden the base of support
The nurse uses family-centered care to care for children in a pediatric office. Upon what concept is family-centered care based?
The family is the constant in the child's life and the primary source of strength.
When assessing for proper body alignment of a standing patient, which of the following is a normal finding?
The weight of the body is distributed on the soles and heels
The nurse is preparing a child and his family for a lumbar puncture. Which of the following would be a primary intervention instituted by the CLS to keep the child safe?
Therapeutic hugging Therapeutic hugging (a holding position that promotes close physical contact between the child and a parent or caregiver) may be used for certain procedures or treatments where the child must remain still. Alternatively, distraction or stimulation (such as with a toy) can help to gain the child's cooperation, but therapeutic hugging would be used to keep the child safe during the procedure. Therapeutic touch is an energy therapy used to promote healing and decrease anxiety and stress and is not related to safety.
A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?
abduction
When assessing the physical activity of clients, the nurse would be most concerned about which client?
the middle-age computer programmer
An 81-year-old patient is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the patient wandering in the hall. He says he is looking for his wife. The nursing approach should be to:
remind him of where he is and assess why he is having difficulty sleeping.
