NURS 1100 - Exam 3
Which description best matches a lay doula? A person who assists in the personal tasks of a mother A woman who is skilled in aiding the deliveries of babies A certified health care provider focused on the care of patients A support person to assist women who have no other source of support during labor
A support person to assist women who have no other source of support during labor A lay doula is a support person present during labor to assist women who have no other source of support. A person who assists in personal tasks of a mother during or after delivery is known as an assistant. A midwife is a woman who is skilled in aiding the deliveries of babies. The nurse is a certified health care provider focused on the care of patients.
Which characteristic would the nurse infer from the nonverbal cues of a patient who has a quick and purposeful gait? The patient is attentive. The patient is fatigued. The patient is depressed. The patient is confident.
The patient is confident. A quick and purposeful gait indicates well-being and confidence. Posture and gait convey important clues about a patient's health. A patient who is attentive may lean forward. Fatigue or depression is indicated by a slumped posture and slow, shuffling gait.
Which therapy does the nurse suggest to help older adults recall their past to resolve current conflicts? Reminiscence Validation therapy Reality orientation Therapeutic communication
Reminiscence Reminiscence as a therapy uses the recollection of the past to understand and resolve current conflicts. It is a way to express personal identity and be optimistic. Validation therapy is an alternative approach to treat older adults who are confused about the present situation. Reality orientation is a communication technique that helps older adults restore a sense of reality and improve the level of awareness. Therapeutic communication skills enable the nurse to perceive and respect the older adult's uniqueness and health care expectations.
Which place is appropriate to document urine output in the patient's chart? Admission sheet Operative report Physician's prescription sheet Flow sheet
Flow sheet A flow sheet is used when repeated observations are to be recorded in a quick and accurate manner. The information from a flow sheet is also retrieved quickly. An admission sheet is used to record the detailed initial assessment at the time of admission. An operative report records the summary of the patient's surgery, complications, and preoperative and postoperative diagnoses. The physician's prescription sheet contains the information of the physician's prescriptions for treatment and medications with date, time, and signature.
Which system is affected in periodontal disease? Respiratory system Neurological system Genitourinary system Gastrointestinal system
Gastrointestinal system Periodontal disease may occur as a physiological change in the gastrointestinal system with aging. The respiratory system is characterized by increased cough reflex, decreased cilia, and fewer alveoli. Physiological changes in the neurological system include degeneration of nerve cells and degeneration of neurons. Physiological changes in the genitourinary system include decreased nephrons and decreased bladder capacity.
Which statement by the nurse indicates a correct understanding of the elements of professional communication? Select all that apply. One, some, or all responses may be correct. "I should introduce myself by giving my name and title." "I will address patients by their first names during initial interactions." "I should address patients with a confused cognitive status by their last names." "I will avoid referring to patients by diagnosis, room number, or other attributes." "I should avoid terms such as 'honey,' 'dear,' or 'grandma' while addressing the patients."
"I should introduce myself by giving my name and title." "I will avoid referring to patients by diagnosis, room number, or other attributes." "I should avoid terms such as 'honey,' 'dear,' or 'grandma' while addressing the patients." The nurse would have a correct understanding by the following statements: "I should introduce myself by giving my name and title," "I will avoid referring to patients by diagnosis, room number, or other attributes," and "I should avoid terms such as 'honey,' 'dear,' or 'grandma' while addressing the patients." The nurse should introduce him- or herself by giving his or her name and status, such as nursing student, registered nurse (RN), or licensed practical nurse (LPN). It is important that the nurse avoid referring to patients by diagnosis, room number, or other attributes, because this approach would be demeaning to patients. The nurse should avoid terms of endearment while addressing patients, even with close nurse-patient relationships. Addressing patients by the last name is respectful in most cultures; nurses usually use a patient's last name in an initial interaction and then use the first name if the patient requests it. Using first names is appropriate for infants, young children, and patients who are confused or unconscious, as well as close team members.
What is the minimum font size (in points) that should be used for the print for a visually impaired patient? Record your answer using a whole number. ________
14
Which describes gynecomastia? Enlarged breasts in men Atrophy of glandular tissue Replacement of milk ducts by fat Decreased muscle mass, tone, and elasticity of the breast
Enlarged breasts in men Enlargement of breasts in men is called gynecomastia. It occurs because of medication side effects, hormonal changes, or obesity. Atrophy of glandular tissue; replacement of milk ducts by fat; and decreased muscle mass, tone, and elasticity of the breast are not signs of gynecomastia. They are normal aging effects.
Which baby would the nurse expect to have no head lag? 1-month-old 2-month-old 3-month-old 4-month-old
4-month-old As babies grow, gross-motor skills are developed. A 4-month-old baby is usually able to hold the head up and has no head lag. Babies younger than 4 months of age may not be developed enough to hold their heads up.
At which age should a child be able to perform fine-motor skills such as transferring objects from hand to hand? 2 to 4 months 4 to 6 months 6 to 8 months 8 to 10 months
6 to 8 months At the age of 6 to 8 months, infants start to perform fine-motor skills such as transferring objects from hand to hand, banging objects together, and pulling strings to obtain an object. At the age of 2 to 4 months, the infant can hold a rattle for short periods, look at and play with fingers, and bring objects from hand to mouth. At the age of 4 to 6 months, the infant is able to grasp objects at will and can drop them to pick up another objects; however, children at this age are not expected to be able to transfer objects from hand to hand. At the age of 8 to 10 months, the infant is able to pick up small objects and shows hand preference.
Approximately how many centimeters does a toddler grow each year? 1.7 3.5 6.2 7.5
7.5 Toddlers experience rapid physical growth. A toddler may grow approximately 7.5 cm in height each year. The weight gain is generally 4 to 6 lb each year.
At which age would a baby be expected to crawl on the floor using his or her arms? 2 to 4 months 4 to 6 months 6 to 8 months 8 to 10 months
8 to 10 months At 5 months of age, an infant may be able to turn himself or herself from the abdomen to the back. An infant who is 2 to 4 months old can turn to the sides. An infant who is 6 to 8 months old can sit alone without support. An infant who is 8 to 10 months old can crawl on the floor using his or her arms.
Which distance of personal space is involved when giving a verbal report to a group of nurses? 2 feet (61 cm) 3 feet (91 cm) 9 feet (274 cm) 13 feet (396 cm)
9 feet (274 cm) Nine feet (264 cm) is the distance when giving a verbal report to a group of nurses. While giving verbal report to a group of nurses, this is a social distance of 4 to 12 feet (122 to 366 cm). Two and 3 feet (61 and 91 cm) are too close, while 13 feet (396 cm) is too far. While taking a patient's nursing history or teaching an individual patient, a personal distance of 18 inches (46 cm) to 40 inches (102 cm) is followed. While speaking at a community forum, a public zone of 12 feet (366 cm) or more is typical.
Which patient is likely to experience anticipatory grief? A man diagnosed with gallstones A teenager who fractured the left leg An older adult diagnosed with a stage 1 pressure injury A middle-age adult diagnosed with amyotrophic lateral sclerosis (ALS)
A middle-age adult diagnosed with amyotrophic lateral sclerosis (ALS) A middle-age adult diagnosed with ALS is likely to experience anticipatory grief, because there is no cure for this disease. In situations of prolonged or predicted loss, such as in ALS, anticipatory grief is common. Gallstones can be cured and does not require anticipatory grieving. A leg fracture can be treated completely and does not require anticipatory grief. Stage I pressure injury can be cured with appropriate treatment; therefore anticipatory grief is unnecessary.
Which hallmark of emotional health indicates successful maturation in a young adult? Select all that apply. One, some, or all responses may be correct. Sensitivity to criticism A sense of meaning and direction in life Unrealistic fears Satisfaction with friendships Generally cheerful attitude Attainment of several long-term goals
A sense of meaning and direction in life, Satisfaction with friendships, Generally cheerful attitude Attainment of several long-term goalsDuring psychosocial assessment of young adults, the nurse should assess for 10 hallmarks of emotional health that indicate successful maturation in this developmental stage. These include a sense of meaning and direction in life and satisfaction with friendships. The young adult is generally cheerful. The young adult has a sense of accomplishment with attainment of several long-term goals. A mature adult is not sensitive to criticism and does not have unrealistic fears.
Which factor would the nurse consider when communicating with adolescents? Be alert for clues to their emotional state. Ask closed-ended questions to get straight answers. Avoid looking for meaning behind adolescents' words or actions. Avoid discussing sensitive issues such as sex and drugs.
Be alert for clues to their emotional state. Adolescents are searching for their identities and trying to become emotionally independent from parents while still maintaining family ties. Depression, substance abuse, and violence are all real concerns during this period; thus, the nurse must be aware of an adolescent's emotional state. Open-ended questions are used to get more detailed answers. The nurse would look for meaning behind adolescents' words or actions. It is also important to discuss issues such as sex and drugs; sex and drugs are very important issues during this age
When does the anterior fontanelle close? Between 1 and 6 months Between 6 and 12 months Between 12 and 18 months Between 18 and 24 months
Between 12 and 18 months The anterior fontanelle is diamond shaped and has frontal and parietal bones surrounding it. The anterior fontanelle is usually palpable in infants and closes by 12 to 18 months. Before 12 months, the skull bones and sutures are too tender to ossify and close. By 18 months of age, the skull bones usually ossify, and it is too late for a fontanelle to close after that. The posterior fontanelle closes by the end of the second or third month.
Which stage of dying, according to the Kübler-Ross theory, is reflected in the patient's statement, "I miss my partner. I will never get my partner back?" Anger Denial Bargaining Acceptance
Acceptance The patient is exhibiting the acceptance stage. The Kübler-Ross theory consists of five stages of dying. When the patient accepts the death of the partner, it indicates acceptance. When the patient says that the partner will be missed and he or she will never get the partner back, it does not indicate anger, denial, or bargaining. When the patient expresses anger or resistance toward God or others, it indicates anger. When the patient cannot accept the loss, it indicates denial. When the patient postpones awareness of the loss by trying to prevent it from happening, it indicates bargaining.
Which action shown by the registered nurse reflects integrity? Admitting own mistakes Blaming the staff nurse Doubting one's own ideas Always taking the suggestions of others
Admitting own mistakes The professional nurse always follows good standards for patient care. The nurse demonstrates a high level of integrity by admitting mistakes and being honest. The nurse builds trust with the other staff and does not blame them. Professional nurses should believe in their own ideas and be able to make their own decisions.
Which clinical feature is related to depression in older adults? Apraxia Agitation Hypervigilance Impaired orientation
Agitation Psychomotor disorientation, or agitation, is commonly seen in patients with depression. Apraxia is a clinical feature associated with dementia but not depression. Patients with delirium have increased alertness (hypervigilance). However, the alertness in patients with depression is usually normal. Impaired orientation is associated with delirium, and patients with depression may have selective disorientation.
Which factor has been linked to intimate partner violence (IPV)? Select all that apply. One, some, or all responses may be correct. Alcohol abuse Pregnancy Unemployment Drug use Religion
Alcohol abuse-Pregnancy-Unemployment-Drug use IPV has been linked to alcohol abuse, especially heavy drinking; stress from the unemployment of the perpetrator; drug use; and pregnancy. The greatest risk of IPV occurs during the reproductive years, with a pregnant woman having a 35.6% greater risk of being a victim of IPV than a nonpregnant woman. Religion is not linked to IPV.
Which statement best explains sexuality in an older adult? When the sexual partner passes away, the survivor no longer feels sexual. A decrease in an older adult's libido occurs. Any outward expression of sexuality suggests that the older adult is having a developmental problem. All older adults, whether healthy or frail, need to express sexual feelings.
All older adults, whether healthy or frail, need to express sexual feelings. Sexuality is normal throughout the life span, and older adults need to be able to express their sexual feelings. Even when a sexual partner passes away, the survivor will still feel the need to express sexual feelings, even if it takes time. Not all older adults experience a decrease in libido. An outward expression of sexuality is normal and does not indicate a developmental problem.
Which physical change occurs during adolescence? Elongation of limbs Slow and consistent growth rate Improved large muscle coordination Alteration in distribution of muscle and fat
Alteration in distribution of muscle and fat There is a significant alteration in the distribution of fat and muscles within the body of adolescents. Because of the many physical changes, the shoulder and hip width increase, normally increasing the width of the body. Elongation of limbs mostly occurs in the years immediately before the onset of puberty and usually slows by the time of adolescence. Growth rate is slow and consistent in school-age children, whereas the growth rate of the skeleton, muscles, and viscera increases during adolescence. Improved large muscle coordination starts when children are of school age, when the strength of the child doubles.
Which loss occurs when the lost person is physically present but not psychologically available? Actual Maturational Necessary Ambiguous
Ambiguous Ambiguous loss is a type of disenfranchised grief that occurs when the person is physically present but not psychologically available. Actual loss occurs when a person no longer can see, feel, or hear a person or object; in this situation the patient is still physically present, making it unrelated to actual loss. Maturational loss is related to normal, expected changes that occur during the life span; a person physically present but unavailable psychologically is not a normal life change. A necessary loss is positive and expected; being unavailable psychologically is not positive.
Which behavior fosters the development of trust? Select all that apply. One, some, or all responses may be correct. Answering the nurse call system promptly Calling the patient by his or her first name unless he or she requests otherwise Completing all care as quickly as possible and leaving the room so the patient can rest Answering questions honestly Demonstrating competence when implementing treatments
Answering the nurse call system promptly Answering questions honestly Demonstrating competence when implementing treatments Consistency, courtesy, competency, and honesty build trust. Rushing and avoiding spending time with the patient may decrease or slow the development of trust.
Which type of grief is exemplified when the parents feel severe grief and loss after seeing their child suffering with cancer? Normal Anticipatory Complicated Disenfranchised
Anticipatory When experiencing anticipatory grief, family members grieve the impending loss of companionship, control, sense of freedom, and the mental and physical changes their loved one will experience. Normal grief is a common and universal reaction to loss or death that may be unexpected or traumatic; normal grief does not occur until after the loss. In this scenario, grieving is occurring before the loss. In complicated grief, a patient has a prolonged or significantly difficult time moving forward after a loss, not before the actual loss, as in this situation. Disenfranchised grief is experienced by a patient when the relationship to the deceased person is not socially sanctioned, cannot be shared openly, or seems of lesser significance; the bond of parents and their children is a socially sanctioned relationship and would not be considered disenfranchised grief.
Which technique would the nurse use to communicate actively with a terminally ill patient? Asking closed-ended questions Sympathizing with the patient Avoiding sensitive issues Asking open-ended questions
Asking open-ended questions The nurse can actively communicate with patients by asking open-ended questions. This helps patients expand their thoughts and tell their stories. The nurse would avoid using closed-ended questions, such as ones with a "yes" or "no" response, because they will not help the nurse understand the feelings and emotions of the patients, and closed-ended questions are not active communication. Being sympathetic will not necessarily allow patients to express feelings and will not allow active communication. The nurse would not avoid sensitive issue as this would not facilitate active communication. Do not avoid talking about a topic; nurses must use therapeutic techniques to discuss sensitive issues.
Which nursing intervention would be beneficial for older-adult patients who are diagnosed with chronic obstructive lung disease (COPD)? Select all that apply. One, some, or all responses may be correct. Assessing for bacterial infection Monitoring blood pressure frequently Placing a feather pillow under the head Monitoring changes in peripheral pulses Monitoring respirations and breath sounds
Assessing for bacterial infection, Monitoring respirations and breath sounds. Older adult patients with COPD are at higher risk of bacterial and viral infection. Therefore the nurse needs to monitor for bacterial infection. Patients with COPD may have apnea. Therefore the nurse needs to monitor respirations and breath sounds. Frequent monitoring of blood pressure would not be of benefit to a patient with COPD. Keeping a feather pillow under the head of the patient can precipitate allergic respiratory reactions that may exaggerate the condition. Monitoring changes in peripheral pulses would be beneficial for the patient with heart and vascular disorders, not COPD.
Which condition is linked to obesity? Select all that apply. One, some, or all responses may be correct. Asthma Hypotension Type 1 diabetes Psoriatic arthritis Hypercholesterolemia
Asthma-Psoriatic arthritis-Hypercholesterolemia Obesity is linked to conditions such as asthma, joint conditions such as psoriatic arthritis, and high cholesterol. Obesity does not cause hypotension, but instead causes hypertension. Obesity is linked to type 2 diabetes. The link to type 1 diabetes is not known.
Which statement is true regarding dementia? Onset is sudden. The condition worsens during the daytime. The effects of dementia are self-limited. Attention is not affected.
Attention is not affected. Patients with dementia experience no effect on their attention. Delirium, not dementia, is a state of reduced mental ability, severe enough to interfere with daily activities. Dementia starts slowly and is often unrecognized. Dementia does not worsen either in the daytime or at night. It lasts for months to years
Which critical thinking model component will the nurse use to deliver empathetic, high-quality, supportive care while planning treatment for a patient experiencing grief and loss? Attitudes Standards Experience Knowledge
Attitudes Attitudes are the critical thinking model component to deliver empathetic, high-quality, supportive care. The standards approach is used to provide privacy for the patient and family and apply ethical principles of autonomy in supporting the patient's choice regarding treatment; it is not the element to deliver empathetic, high-quality, supportive care. The experience approach uses previous patient responses to planned nursing interventions for pain and symptom management or loss of a significant other; it is not the component that focuses on delivering empathetic, high-quality, supportive care. The knowledge approach uses spirituality and other health professions as resources for dealing with loss; it is not the element that delivers empathetic, high-quality, supportive care.
The nurse states that being self-directed and independent are essential for accomplishing goals. Which element of communication is the nurse describing? Empathy Autonomy Courtesy Assertiveness
Autonomy Autonomy refers to the state of being self-directed and independent in accomplishing goals and advocating for others. Empathy is the ability to understand a person's reality. Saying hello or goodbye to a patient or knocking on the door before entering a patient's room are gestures of courtesy. Assertiveness is the ability to express opinions without being judgmental.
The student nurse is assigned to check the blood pressure of a patient and refers to the manual before doing so. Which level of thinking does this illustrate? Basic Complex Commitment Intermediate
Basic A learner has basic critical thinking. A basic critical thinker always has faith in the experts. The learner tends to consult books or experts before making a decision or performing a task. A complex critical thinker analyzes a situation before making a decision. In commitment thinking, the person makes decisions without any assistance and is accountable for the decisions made. There is no intermediate level of thinking.
A 40-year-old patient is admitted with severe pain in the lower abdomen. A newly hired nurse is assigned to care for this patient. Which level of critical thinking according to Kataoka-Yahiro and Saylor's model would the nurse use? Select all that apply. One, some, or all responses may be correct. Basic Complex Advanced Intermediate Commitment
Basic Complex Commitment There are three levels of critical thinking: basic, complex, and commitment. In the basic level, nurses follow whatever instructions experts or manuals tell them. At this level the nurse's experience is low. In the complex level, the nurse begins to analyze the situation independently and does not just follow the experts. At the commitment level, the nurse anticipates when to make decisions without assistance from others. The experience is high at this level. Advanced and intermediate are not levels included in the critical thinking model for nursing judgement.
Which clinical feature is associated with delirium? Lasts for months to years Minimal impairment of attention Onset is slow and often unrecognized Calls out repeatedly with the same phrase
Calls out repeatedly with the same phrase Clinical features of delirium include calling out repeatedly with the same phrase; duration is hours to less than 1 month, longer if unrecognized and untreated (dementia and depression last months to years); attention is impaired and fluctuates (attention is generally normal with dementia and depression); and sudden/abrupt onset and progression (onset is insidious and often unrecognized with dementia, and depression often happens abruptly with major life changes).
Which common issue might the nurse observe while assessing patients who are between 35 and 64 years of age? Select all that apply. One, some, or all responses may be correct. Gender identity Sexual preferences Vocational choices Career-related changes Caring for aging parents
Career-related changes-Caring for aging parents Each age-group faces common issues because of the developmental tasks of that age. Middle adulthood is the period from 35 to 64 years of age. Career-related changes and caring for aging parents are common issues during middle adulthood. Young adulthood is the period from 18 to 34 years of age. Issues of gender identity and sexual preferences are common during young adulthood; these form the basis of young adults' social identity. Decisions about college and vocational choices are also common during young adulthood.
According to R.W. Paul, which intellectual standard would the nurse have for critical thinking? Select all that apply. One, some, or all responses may be correct. Clear Intuitive Plausible General Complete
Clear Plausible Complete According to Paul, there are 14 intellectual standards universal for critical thinking: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for purpose), and fair. These are guidelines or principles to enhance rational thinking that can be used in daily nursing practice.
Which description is accurate for a system warning alerting the nurse an intervention is inappropriate for a patient because of risk? Electronic health record Clinical documentation Clinical decision support system Computerized provider order entry
Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. An electronic health record, clinical documentation, and computerized provider order entry are not types of warnings alerting nurses to potential safety issues.
Which attitude is essential for critical thinking? Select all that apply. One, some, or all responses may be correct. Confidence Risk avoidance Fairness Discipline Curiosity
Confidence Fairness Discipline Curiosity Certain attitudes are essential for critical thinking. Nurses should have confidence in their knowledge and abilities. Nurses should be fair in the care they provide. Discipline helps in the thorough and critical assessment of any problem. Curiosity helps the nurse question existing practices and improves the standard of care. Risk-taking abilities help the nurse implement new standards of care, but the risks should always be calculated.
Which special zone of touch requires the nurse to get permission to take a pulse at a patient`s wrist? Social Consent Intimate Vulnerable
Consent The consent zone requires permission to touch a patient's wrist. In the consent zone, the nurse needs permission to touch a patient`s mouth, wrists, and feet. In the social zone, the nurse does not need permission to touch the patient's hands, arms, back, or shoulders. In the intimate zone, great sensitivity and permission are needed in the areas involving the genitalia and rectum. In the vulnerable zone, the nurse takes special care to handle the patient`s face, neck, and front of the body.
Use of the pain scale is an example of which intellectual standard? Deep Relevant Consistent Significant
Consistent Use of the same pain scale for assessing pain acuity is an example of being consistent. A deep intellectual standard is one containing complexities and multiple relationships, a relevant intellectual standard is crucial to a specific situation, and a significant intellectual standard focuses on what is important.
Which endocrine change is associated with aging? Increased insulin sensitivity Increased thyroid secretions Decreased ability to respond to stress Decreased antiinflammatory hormone secretions
Decreased ability to respond to stress Aging decreases the ability to respond to stress because the functional ability of the body declines with age, and hormone production is altered. Aging decreases insulin sensitivity because of reduced body weight. The thyroid gland becomes nodular with age, which results in decreased thyroid secretions. Antiinflammatory hormones are increased in older adults because of degenerative changes and oxidative stress.
Which physiological change occurs with aging? Decreased stomach pH Decreased bladder capacity Decreased airway resistance Increased peripheral circulation
Decreased bladder capacity Aging, the process of becoming older, decreases bladder capacity because the bladder elasticity decreases. The stomach pH increases with aging because the body produces less hydrochloric acid with advancing age. Aging decreases upper airway size and results in increased airway resistance. Peripheral circulation decreases with aging because of a narrowing of the arteries.
An older patient with vomiting and diarrhea is at risk of which condition? Pneumonia Dehydration Heart failure Urinary tract infection (UTI)
Dehydration Vomiting and diarrhea decrease water content, which causes the patient to be at risk of dehydration. A decrease in a patient's appetite may indicate that the patient is at risk of pneumonia because appetite can decrease as a result of breathing problems. A decrease in a patient's appetite may indicate that the patient is at risk of heart failure because fluid is built up near the liver; this causes the appetite to decrease. A decrease in a patient's appetite indicates that the patient is at risk of a UTI because a bacterial infection may cause a decrease in appetite.
Which stage of the Kübler-Ross theory is reflected in the patient's statement, "I will seek a second opinion and have the tests done again at another hospital?" Anger Denial Bargaining Depression
Denial Saying "I will seek a second opinion and have the tests done again at another hospital" indicates denial. The Kübler-Ross theory (1969) consists of five stages. When the patient is unable to accept the fact that he or she is dying, it indicates denial. As a result, the patient wants to perform the tests again at another hospital. Anger is the expression of resistance or anger toward God or other people, not seeking a second opinion. Bargaining is characterized by postponing awareness of the loss by trying to prevent it from happening, not by seeking a second opinion. Depression is characterized by the individual realizing the full impact of the loss. The patient is not realizing the full impact; in fact, the patient in this situation is in denial wanting a second opinion as a form of psychological protection.
Persistent pain can lead to which consequence? Select all that apply. One, some, or all responses may be correct. Depression Changes in gait Sleep difficulties Impaired cognition Fear of using analgesics
Depression + Changes in gait + Sleep difficulties Pain is a symptom and a sensation of distress. Consequences of persistent pain are depression, changes in gait, and sleep difficulties. Because of the pain, the person may not socialize with others. Pain does not impair cognition. Fear of using analgesics may cause the pain to persist for a longer time, but it is not a consequence of persistent pain.
Which clinical manifestation may present in a patient with dementia? Incoherent speech Impaired attention Difficulty with abstraction Difficulty distinguishing between reality and misperceptions
Difficulty with abstraction A patient with dementia may face difficulty with abstraction. Incoherent speech may be associated with a patient with delirium. Attention may be altered in a patient with delirium; however, patients with dementia generally have normal attention. Misperceptions are usually absent in dementia. However, in delirium, the patient may find it difficult to distinguish between reality and misperceptions.
Which age-related finding related to reproductive health can be seen in an older adult female patient? Select all that apply. One, some, or all responses may be correct. Dry vagina Firm breasts Large breasts Presence of pubic hair Reduced size of the vagina
Dry vagina and Reduced size of the vagina The production of estrogen in women declines with age. As estrogen levels decline, vaginal dryness occurs. Aging is also associated with atrophy of the vagina. Atrophy here refers to reduction in size. Because of reduced estrogen levels with aging, breasts become less firm and reduce in size. Pubic hair starts growing after puberty; therefore the presence of pubic hair is not an age-related finding.
Which factor may influence how well a patient with diabetes adheres to a self-care and drug regimen? Select all that apply. One, some, or all responses may be correct. Family of the patient Education level of the patient Socioeconomic status of the patient Physical status of the patient Motivation level of the patient
Education level of the patient-Socioeconomic status of the patient-Motivation level of the patient Factors such as the education level, socioeconomic status, and the motivation level of the patient determine how well he or she adheres to a particular therapy. The patient's family and the physical status of the patient do not affect adherence to a particular regimen.
According to attachment theory, which action represents disorganization and despair? Feeling lethargic and loss of appetite Emotional outbursts of tearful sobbing Separating oneself from the lost relationship Endless examination of how and why the loss has occurred
Endless examination of how and why the loss has occurred According to attachment theory, endless examination of how and why the loss has occurred represents disorganization and despair. Feeling lethargic, loss of appetite, and emotional outbursts of tearful sobbing represent yearning and searching, not disorganization and despair. In the stage of reorganization (not disorganization and despair), the person separates him- or herself from the lost relationship.
Which sense is affected by presbycusis? Hearing Sight Taste Touch
Hearing Presbycusis is characterized by the presence of a loss of acuity for high-frequency tones and conversational speeches resulting from aging. It is a physiological sensory change that may occur in the ears with aging. Sensory changes in the eyes include yellowing of the lens and altered color perception. A sensory change in taste is often characterized by fewer taste buds. A sensory change in touch might be caused by fewer skin receptors.
In which health care setting would the nurse find an older adult with chronic dehydration exacerbated by acute illness? Home care Nursing home care Hospital care Ambulatory care
Hospital care In a hospital care setting, an older adult may experience chronic dehydration exacerbated by acute illness; this could occur because of medications and diagnostic procedures that limit the intake of fluids. In a home care setting, older adults with late-stage heart disease should be monitored for loss of appetite. In a nursing home setting, patients should be observed for a decline in functional ability, which may indicate the onset of illness. An older patient who seeks ambulatory care with a complaint of fatigue and limited ability to perform normal activities may have thyroid problems, anemia, or cardiac problems.
Arrange the steps of the scientific method in the correct sequence. Formulating a question or hypothesis Testing the question or hypothesis Identifying the problem Collecting data Evaluating results of the study
Identifying the problem Collecting data Formulating a question or hypothesis Testing the question or hypothesis Evaluating results of the study The scientific method is a general critical thinking approach. It is not specific to clinical nursing and can be applied to other practices as well, especially nursing research. The scientific method consists of five steps. The first steps are to identify the problem that exists and collect relevant data. The data are helpful to formulate a question or a hypothesis that can be tested, which is the next step. The final steps are to test the hypothesis and evaluate the results.
Which factor contributes to weight loss in a 7-month-old child? Cessation of mother's milk Inclusion of fortified milk in the child's diet Dehydration pertaining to adaptation to new foods Inclusion of fruit juices instead of whole fruits in the diet
Inclusion of fruit juices instead of whole fruits in the diet The use of fruit juices and non-nutritive drinks does not provide sufficient calories during the second 6 months of life. On the contrary, solid foods like whole fruits, vegetables, and meat provide additional sources of nutrients. Stopping the mother's milk completely would not affect the body weight because other dietary supplements are available to properly nourish the child. Fortified milk supplements are used as alternatives to breast milk to provide adequate nutrition to infants. Frequent dehydration most often occurs in severe pathological conditions and usually does not occur with the introduction to new foods.
Which physiological change of the endocrine system occurs because of aging? Decreased fibrosis Increased thyroid secretions Increased antiinflammatory hormones Increased secretions of pancreatic enzymes
Increased antiinflammatory hormones An increase in the production of glucocorticoids occurs during aging, which, in turn, increases the production of antiinflammatory hormones. In older adults, there is increased fibrosis and a decrease in thyroid gland secretions that occur. In older adults, there is a decrease in pancreatic enzyme production with a decreased ability to respond to stress.
Which respiratory change occurs in older adults? Increased cilia Increased alveoli Increased cough reflex Increased chest wall rigidity
Increased chest wall rigidity Chest wall rigidity is increased in older adults; it becomes stiffer and more rigid as age progresses as a result of rib and cartilaginous calcification. The number of cilia decreases as age progresses. The number of alveoli is less, and the cough
Which form of communication is appropriate to assess understanding and clarify misinterpretations when the nurse is teaching a patient about a health concern? Public Small-group Intrapersonal Interpersonal
Interpersonal Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face-to-face. This interaction is useful to assess understanding and clarify misinterpretations when teaching a patient about a health concern. Public communication is interaction with an audience. Nurses often speak with groups of consumers about health-related topics; however, this scenario dealt with just a nurse and a patient. Small-group communication occurs when a small number of people meet, not just a nurse and patient. This type of communication is usually goal directed and requires an understanding of group dynamics. Intrapersonal communication is a powerful form of communication that one uses as a professional nurse. This level of communication is also called self-talk; it does not involve communication with another person.
Which concept is a barrier that health care providers must overcome to promote health and control disease in older adults? Health literacy Personal motivation Lack of consistent guidelines Previous health care experiences
Lack of consistent guidelines Lack of consistent guidelines is a barrier that health care providers must overcome for health promotion and disease control in older adults. Health literacy, personal motivation, and previous health care experiences are the barriers that older adults themselves must overcome.
A patient is in labor with her first baby, which is coming 2 weeks early. Her husband is in the military and might not get back in time, and neither family is able to be with her during labor. Which support person employed by the birthing area is the health care provider most likely to call in to be present during labor? Nurse Midwife Assistant Lay doula
Lay doula A lay doula is a support person who is present during labor to assist women who have no other source of support. This woman has no family available to support her during the laboring process and delivery. Although the nurse and a midwife would be supportive during labor, the scope of practice for nurses and midwives far exceeds that of a support person present during labor. An assistant is incorrect.
Which perspective is based on the principle that individuals develop new abilities to compensate for some of their decreased physical abilities as they age? Life span approach Stage-crisis theory Piaget's theory Temperament theory
Life span approach The life span approach is based on the principle that individuals develop new abilities to compensate for some of their decreased physical abilities as they age. This approach also takes into consideration the situation of the individual person. Stage-crisis theory is based on developmental tasks that evolve from physical maturation, personal values, and pressures from society. Piaget's theory is based on cognitive thinking, whereas temperament theory is based on the behavior of individuals and has three classes based on temperament.
Which nursing intervention would the nurse include in the care plan for a terminally ill patient? Select all that apply. One, some, or all responses may be correct. Maintain comfort. Discuss options for euthanasia. Preserve dignity and quality of life. Provide social support to family members. Offer economic support to family members.
Maintain comfort. Preserve dignity and quality of life. Provide social support to family members. The nursing care plan should focus on maintaining comfort, preserving dignity and quality of life, and providing social support to family members. Terminally ill patients should be allowed to spend the rest of their days in as much comfort and peace as is possible given the patient's condition. The plan should also include providing social support to family members to prepare to grieve their loss. Euthanasia is a controversial issue, and nurses do not take part in that decision. The nurse would not provide economic support to family members.
Which statement about perimenopause is true? Menstruation cycles no longer occur. Menstrual cycles become irregular. Estrogen and progesterone are no longer produced. The neurohormonal system fails to stimulate the endocrine system.
Menstrual cycles become irregular. Perimenopause is the period before menopause when the ovarian function starts declining. Ova production decreases and menstrual cycles become irregular. The cessation of menses, the cessation of the production of estrogen and progesterone, and failure of the neurohormonal system to stimulate the endocrine system are characteristics of menopause.
Which effect does reality orientation have on the older adult? Select all that apply. One, some, or all responses may be correct. Minimizing confusion Promoting socialization Restoring a sense of reality Improving the level of awareness Providing assistance for functioning
Minimizing confusion + Promoting socialization + Restoring a sense of reality + Improving the level of awareness Reality orientation makes an older adult more aware of time, place, and person. The purposes of reality orientation include minimizing confusion, promoting socialization, restoring a sense of reality, and improving the level of awareness. Orientation to time, place, and person helps decrease confusion and helps the patient communicate effectively with others. It also restores a sense of reality, thus increasing awareness in the patient. It does not provide assistance for functioning.
Which factor, aside from educational level and socioeconomic status, affects a patient's compliance with a prescribed course of therapy? Gender Lifestyle Motivation Family history
Motivation Motivation plays a key role in compliance with a prescribed course of therapy. However, motivation can be influenced by a variety of factors, including age, experience, family history, social support, and pressure from health care providers.
Which physical change in the patient suggests that death is near? Select all that apply. One, some, or all responses may be correct. Noisy respirations Increased urine output Decreased muscle tone Decreased intake of food Decreased periods of sleeping
Noisy respirations Decreased muscle tone Decreased intake of food The physical changes include noisy respirations, decreased muscle tone, and decreased intake of food. As a patient nears death, body systems tend to slow down. Noisy respirations are caused by pooling of secretions in the airway. Muscle tone is reduced as the muscles become flaccid. Food intake is usually reduced because of the failure of the gastrointestinal system to function properly. Urine output is decreased (not increased) because fluid intake is reduced and the urinary system stops working. A dying patient has increased (not decreased) periods of sleeping. The patient tends to sleep most of the time because the brain and nervous system slow down their functions.
A health care organization has incorporated information and computer technology. Which system will help the organization comply with the requirements of accrediting agencies? Nursing documentation system Clinical decision support system Nursing clinical information system Bar-code medication administration system
Nursing clinical information system The nursing clinical information system will help the organization comply with the requirements of accrediting agencies. A nursing documentation system helps in facilitating continuity of care. Clinical decision support systems are computerized programs used within health care settings. A bar-code medication administration system is used to document the administration of the dosage form to the patients.
Which professional is permitted to perform a prenatal assessment of a pregnant woman? Select all that apply. One, some, or all responses may be correct. Lay doula Obstetrician Registered nurse Certified midwife Nurse practitioner
Obstetrician + Certified midwife + Nurse practitioner The obstetrician or an advanced nursing professional such as a certified midwife or nurse practitioner perform the prenatal examination. A registered nurse does not provide prenatal care. A lay doula is a nonmedical support person who is present during labor to assist women who have no other source of support. A lay doula does not provide prenatal care.
Which characteristics are a component of critical thinking? Select all that apply. One, some, or all responses may be correct. Open-mindedness, continual inquiry, and perseverance Reliance on laboratory reports and diagnostic results to assess patients Recognition of an issue, analysis of related information, and formation of conclusions Imagination and exploration of alternatives, consideration of ethical principles, and informed decision-making Low consideration of what the patient says, preference for diagnostic tests and scientific data
Open-mindedness, continual inquiry, and perseverance Recognition of an issue, analysis of related information, and formation of conclusions Imagination and exploration of alternatives, consideration of ethical principles, and informed decision-making Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance. It may help the nurse to be open to new ideas and incorporate modifications. Critical thinking involves recognizing that an issue exists, analyzing information about the issue, evaluating information, and making conclusions. Coming to a logical solution for a patient health problem is a step-by-step process. A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Critical thinking does not depend only on diagnostic reports and analysis.
Which factor places an older adult at risk of falls? Select all that apply. One, some, or all responses may be correct. Osteoporosis Airway blockages Impaired hearing Alterations in bladder function Cognitive impairment Peripheral neuropathy
Osteoporosis, Alterations in bladder function, Cognitive impairment, Peripheral neuropathy Older adults who are inactive have low bone and muscle mass or muscle tone and are at higher risk of osteoporosis, which can cause falls. Older adults with altered bladder function, such as urinary incontinence and nocturia, are at increased risk of falls. Conditions affecting mobility, such as arthritis and peripheral neuropathy, may lead to falls. Conditions such as cognitive impairment and confusion may cause falls in older adults. Lung injury from smoking leads to the development of chronic obstructive pulmonary disease (COPD), causing airflow blockage and breathing difficulty; airway blockages are not a significant risk factor for falls. Impaired hearing is commonly experienced by older adults; it is not a significant risk factors for falls.
Where does the nurse access the information to contact the guardian of a patient? Discharge summary Nurse's admission assessment Nurse's notes Patient care summary
Patient care summary The patient's care summary contains the patient's demographic data such as name, address, contact numbers, age, date of birth, insurance, employment, and information about the guardian. The nurse accesses the patient's care summary to obtain the contact number of the patient's guardian.
Which physiological change is common in older adults? Select all that apply. One, some, or all responses may be correct. Periodontal disease Loss of skin elasticity Decreased cough reflex Decreased muscle mass Thickening of blood vessel walls Thickening of tympanic membrane
Periodontal disease Loss of skin elasticity Decreased cough reflex Decreased muscle mass Thickening of blood vessel walls Thickening of tympanic membrane Common physiological changes associated with normal aging are not pathological in themselves, but they can make older adults more vulnerable to common clinical conditions and diseases. Changes include periodontal disease; loss of skin elasticity; decreased cough reflex, muscle mass, and strength; thickening of blood vessel walls; degeneration of nerve cells; decreased accommodation to near/far vision; thickening of tympanic membrane and fewer nephrons; and diminished hormone secretion and immune system functioning.
Which pathophysiological change caused by smoking can increase the risk of cardiac disease in young adults? Select all that apply. One, some, or all responses may be correct. Obstruction of airways Peripheral vasoconstriction Coronary vasoconstriction Deposition of fats in coronary arteries Vasodilation of coronary arteries
Peripheral vasoconstriction Coronary vasoconstriction Deposition of fats in coronary arteries Smoking causes peripheral vasoconstriction, which raises blood pressure and increases the risk of cardiac disease. Coronary vasoconstriction and deposition of cholesterol and fats in the coronary arteries are also pathophysiological changes associated with smoking and cause cardiac conditions such as angina, myocardial infarction, and coronary artery disease. Obstruction of airways caused by the pollutants that are inhaled while smoking causes pulmonary conditions, including lung cancer, emphysema, and bronchitis. Vasoconstriction, not vasodilation, increases risk of cardiac disease in young adults.
Sharing eating utensils with a person who has a contagious illness is an example of a health risk resulting from which factor? Lifestyle Community Family history Personal hygiene habits
Personal hygiene habits In all age-groups, personal hygiene habits can be risk factors for the spread of contagious diseases. Sharing eating utensils with a person who has a contagious illness increases the risk of illness. Sharing utensils is not a lifestyle, community, or family history risk.
Which extrinsic factor increases the risk of falls among older adults? Select all that apply. One, some, or all responses may be correct. Poor lighting Inappropriate footwear Adverse medication reactions Improper use of assistive devices Unfamiliar environment of a hospital room
Poor lighting -Inappropriate footwear-Improper use of assistive devices - Unfamiliar environment of a hospital room Poor lighting, inappropriate footwear, improper use of assistive devices, and the unfamiliar environment of a hospital room are extrinsic factors that increase the risk of falls among older adults. Poor lighting makes it difficult to see properly. Inappropriate footwear also increases the chance of falling. The improper use of assistive devices such as walkers may lead to falling. The unfamiliar environment of a hospital room may contain barriers to movement, causing the older adult to fall. An adverse medication reaction is an intrinsic factor, not an extrinsic factor.
A patient who delivered a baby 2 days ago is irritable, has mood swings, and is experiencing overall emotional instability. These signs are indicative of which condition? Schizophrenia Postpartum depression Postpartum psychosis Bipolar mood disorder
Postpartum depression Dramatic physical and psychological changes occur after childbirth, causing some women to experience postpartum depression. The signs of this condition include mild irritability, mood swings, and emotional instability. Postpartum women are unlikely to have schizophrenia. Clinical manifestations of postpartum psychosis are very severe; the patient may have delusions, hallucinations, thoughts of harming the baby, unwillingness to eat or sleep, risk of suicide, and severe depression. The mood swings in postpartum depression are not as severe as seen in a bipolar mood disorder.
Which condition does the nurse suspect in an older-adult patient who has reported daily hearing decline? Delirium Dementia Presbyopia Presbycusis
Prebycusis Presbycusis refers to the progressive loss of hearing that occurs with age. Delirium is a cognitive impairment resulting in a confused state. Dementia is an impairment of intellectual functioning that interferes with social and occupational functioning. Presbyopia is a progressive decline of vision.
Which phase of the helping relationship is the nurse exhibiting when reviewing the patient's medical and nursing histories? Working Orientation Termination Preinteraction
Preinteraction Reviewing available data, such as the medical and nursing histories, is included in the preinteraction phase. The phase before meeting a patient is the preinteraction phase. Working phase is when the nurse and patient work together to solve problems and accomplish goals. The nurse and patient meet and get to know one another during the orientation phase. The termination phase occurs at the end of the relationship with the patient.
What is an advantage of summarizing? Select all that apply. One, some, or all responses may be correct. Promotes recall of previous discussions Participants focus on key issues Reveals true personal experiences Useful in the terminal phases of the patient relationship Brings a sense of caring and human connection
Promotes recall of previous discussions Participants focus on key issues Useful in the terminal phases of the patient relationship Summarizing provides a short review of the key areas of interaction, which helps in recalling previous discussions and makes further discussions easier. Summarizing helps the participants focus on key issues, offers a chance for revision, and makes the interaction more productive. It is also useful in the terminal phases of the patient relationship to sum up the discussion. Using this technique, any points that are misunderstood can be clarified. Revealing true personal experiences is part of self-disclosure. Using touch, not summarizing, brings a sense of caring and human connection.
Which condition may result in difficulty initiating voiding and maintaining a urinary stream in older adult men? Stress incontinence Prostatic hypertrophy Urinary tract infection Weakened bladder muscles
Prostatic hypertrophy Difficulty initiating voiding and maintaining a consistent urinary stream may occur because of an enlarged prostate, or prostate hypertrophy. Stress incontinence is usually seen in women, and the urine is released involuntarily during sneezing, coughing, and laughing because of stress on the urinary bladder. Urinary tract infections may not lead to an inconsistent urine stream. Weakened bladder muscles lead to urinary incontinence.
Which action falls under the role of a lay doula? Deliver the infant. Administer pain medications to the patient in labor. Monitor vital signs when the patient is in labor. Provide emotional support and physical assistance to the patient in labor.
Provide emotional support and physical assistance to the patient in labor.. The lay doula is a support person who is present during labor to assist women who have no other source of support. The lay doula does not have a medical background and is not licensed to give pain medications to the patient or check vital signs. The obstetrician delivers the infant. Only a licensed nurse practitioner or health care provider can administer pain medications. The nurse checks the patient's vital signs when the patient is in labor.
Which action describes a therapeutic communication technique? Select all that apply. One, some, or all responses may be correct. Provide personal opinion. Provide hope to the patients. Listen actively to the patients. Understand the patients' feelings. Provide sympathy to the patients.
Provide hope to the patients. Listen actively to the patients. Understand the patients' feelings. Therapeutic communication techniques include specific responses to encourage expression while respecting patients. The nurse should provide hope and encouragement to the patient. Active listening helps improve communication with patients. Understanding feelings helps the nurse empathize. Providing personal opinions is nontherapeutic. Providing sympathy is a nontherapeutic approach of communication that shows pity instead of respect to the patient.
Which factor indicates the normal process of aging? Poor judgment Loss of language skills Loss of the ability to calculate Reduced number of brain cells
Reduced number of brain cells Reduction in the number of brain cells is a characteristic feature of the normal aging process. Poor judgment, loss of language skills, and loss of the ability to calculate are not symptoms of cognitive impairment related to the normal aging process. These symptoms hint toward an underlying disease condition.
Which action would the nurse take for a patient newly diagnosed with a serious, life-changing illness whose conversations are abrupt, superficial, and unrelated to the illness? Strongly suggest the patient talk about feelings. Focus on the family to obtain the information needed. Avoid discussing illness-related topics with quiet patients. Remain alert for signals that the patient wants to talk.
Remain alert for signals that the patient wants to talk. The nurse would remain alert for signals that the patient wants to talk. The nurse would make no presumptions about this patient other than the fact that the patient is not yet ready to talk about the situation but would stay alert for a time when ready to talk. Strongly suggesting the patient talk is nontherapeutic as some people do not work through their problems by talking to others. The patient, not the family, is the focus even when that patient is reluctant to talk. The nurse does not avoid discussing illness-related topics as this is nontherapeutic; the nurse would talk about illness-related topics.
Which positive health habit may prevent the development of chronic illness later in life? Select all that apply. One, some, or all responses may be correct. Routine screening and diagnostic tests Unprotected sexual activity Regular exercise Excessive alcohol consumption Driving without a seat belt
Routine screening and diagnostic tests, Regular exercise Routine screening and diagnostic tests (e.g., laboratory screening for serum cholesterol or serum glucose levels, mammography, or colonoscopy) provide early detection of health issues. Regular exercise helps maintain weight and improve musculoskeletal functioning. Unprotected sexual activity may lead to an unplanned pregnancy and sexually transmitted infections. Excessive alcohol intake can lead to liver disease. Driving without a seat belt is a risky behavior and can lead to fatality if involved in a motor vehicle accident.
As taste buds atrophy and lose sensitivity, which taste is the older adult less able to discern? Spicy and bland foods Salty, sweet, sour, and bitter tastes Hot and cold temperatures Moist and dry food
Salty, sweet, sour, and bitter tastes As people age, salivary secretion is reduced, and taste buds atrophy and lose sensitivity. The older adult is less able to differentiate among salty, sweet, sour, and bitter tastes. Often an adult uses heavy spices because of the inability to taste food. Older adults maintain their ability to differentiate between hot and cold temperatures and moist and dry food.
In which stage of Piaget's theory of cognitive development do infants develop a schema or action pattern for dealing with the environment? Sensorimotor Preoperational Formal operations Concrete operations
Sensorimotor Period I is the sensorimotor phase which encompasses birth to 2 years. In this phase, infants develop a schema or action pattern for dealing with the environment. In period II, the preoperational phase, children ages 2 to 7 years learn to think with the use of symbols and mental images. Period IV is the formal operations phase in which there is a transition from concrete to formal operational thinking. In period III, concrete operations for children ages 7 to 11 involve performing mental operations.
Which communication technique is the nurse using when he or she comments on positive aspects of a patient's behavior and response? Sharing hope Sharing feelings Sharing empathy Sharing observations
Sharing hope Commenting on the positive aspects of a patient's behavior and response develops hope in the patient. Sharing feelings involves helping patients share emotions by encouraging openness and modeling healthy self-expression, not commenting on positive aspects. Sharing empathy is the ability to understand the patient's reality, perceive feelings accurately, and communicate this understanding to the patient, not pointing out positive aspects. Sharing observations involves commenting on observations such as the looks, sounds, or actions of the patient, not commenting on positive aspects of the patient's behavior and response.
Which sense is affected by presbyopia? Hearing Sight Smell Taste
Sight Sensory changes in the eyes are characterized by the presence of decreased accommodation to near or far vision, which is called presbyopia. Sensory changes in the ears include thickening of the tympanic membrane and sclerosis of the ear. Sensory changes of smell include a diminished sense of smell. Sensory changes in taste are often characterized by fewer taste buds.
Which type of loss is exemplified when a patient sustains severe injuries leading to loss of function from a motor vehicle accident? Actual Perceived Situational Maturational
Situational The patient is experiencing situational loss because of a sudden and unpredictable external event such as an accident. An actual loss is a loss in which a person can no longer feel, hear, see, or know a person or object; actual loss involves death of a loved one or loss of a body part, not severe injuries leading to loss of function. Perceived loss is a loss in which a person is experiencing a loss, but the loss is less obvious to other people; sustained severe injuries are not less obvious to other people, making perceived loss incorrect. Maturational loss is a form of necessary loss that includes all normally expected life changes across the life span; a motor vehicle accident is not a normal expected life change.
Which statement is true regarding delirium? The onset of delirium is insidious. Sleep/wake cycle is disturbed. The patient with delirium may have normal alertness. Progression of the delirium is slow over months and years.
Sleep/wake cycle is disturbed The sleep/wake cycle is disturbed in delirium. The onset of delirium is sudden or abrupt but not insidious. Alertness in delirium fluctuates and can be lethargic or hypervigilant, but not normal. Progression of delirium is abrupt, not gradual over months and years.
Which term describes the type of communication involved when the nurse teaches individuals about healthy meal planning? Small-group Transpersonal Intrapersonal Nonpersonal
Small-group Small-group communication is a goal-directed type of communication that occurs when a small number of people meet. When a patient is communicating through prayer, meditation, or other means with a higher power or deceased loved one, transpersonal communication is taking place. Intrapersonal communication happens within the person. Nonpersonal is not a type of communication.
Which modifiable risk factor is the most preventable cause of disease and death in the United States? Alcohol Smoking Poor dietary choices Lack of physical exercise
Smoking Cigarette smoking is a risk factor for the four most common causes of death: heart disease, cancer, lung disease, and stroke. It is the most preventable cause of disease and death in the United States. Alcohol use, poor dietary choices, and lack of physical exercises are not the most preventable causes of disease and death in the United States. Studies of alcohol abuse in older adults report two patterns: a lifelong pattern of continuous heavy drinking and a pattern of heavy drinking that begins late in life. Lifelong eating habits and situational factors influence how older adults achieve good nutrition. These habits are based in tradition, cultural habits, and preferences. Older adults need to maintain physical exercise and activity. The primary benefits of exercise include maintaining and strengthening functional ability and promoting a sense of enhanced well-being and quality of life.
Which theory includes denial and acceptance? Stages of dying Attachment theory Rando's "R" process model Grief tasks model
Stages of dying Stages of dying by Kübler-Ross explains denial, anger, bargaining, depression, and acceptance.
Which phase of the helping relationship is represented when the nurse recalls a funny shared experience with a patient shortly before the patient is transferred to another unit? Working Orientation Termination Preinteraction
Termination When the nurse ends the relationship with a patient, it indicates the termination phase of the helping relationship. This phase may involve the nurse and the patient reminiscing about their relationship and what occurred. The working phase involves taking actions to meet the goals set for the patient. The nurse sets the tone for the relationship by adopting a warm, empathetic, caring manner during the orientation phase. The preinteraction phase involves the time before the nurse's initial interaction with the patient.
Which organization addresses the quality of health care documentation? Select all that apply. One, some, or all responses may be correct. American Nurses Association (ANA) The Joint Commission Diagnosis-related groups (DRGs) National Committee for Quality Assurance (NCQA) Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Joint Commission National Committee for Quality Assurance (NCQA) Documentation of health care should conform to the standards of The Joint Commission and the NCQA. This documentation ensures the standards of care are maintained to uphold institutional accreditation and minimize liability. The ANA sets standards for providing safe, effective, patient-centered, timely, and efficient care to the patient. DRGs help establish reimbursement for patient care. HIPAA is the legislation that protects the patient's right to privacy of health information.
Which factor would the nurse assess when determining the knowledge base of a middle-aged adult with chronic illness and his or her family? Select all that apply. One, some, or all responses may be correct. The medical course of the illness The prognosis for the patient Coping mechanisms of the patient and family The need for community and social services The family's nutritional needs
The medical course of the illness The prognosis for the patient Coping mechanisms of the patient and family The need for community and social services When assessing a patient with a chronic illness, the nurse should determine how much the patient and the family know about how the illness has progressed and the long-term prognosis for the patient. This includes understanding the patient's and family's ability and readiness to accept the illness and the outlook for the patient. Understanding the coping mechanisms used by the patient and family helps the nurse to determine how to teach and counsel them about the treatment regimen and whether or not community or social services are needed and will be accepted to help the patient and family.
The nurse is reviewing the diagnostic report of four patients. Which patient will have difficulty hearing the nurse? The patient who has a cataract. The patient who has presbyopia. The patient who has presbycusis. The patient who has macular degeneration.
The patient who has presbycusis. Presbycusis refers to an age-related hearing impairment in older adults. The nurse suspects that the patient who has been diagnosed with presbycusis will have difficulty hearing. The nurse will suspect that the patient with a cataract will have a loss of transparency in the eye lens. The nurse will suspect retinal damage in the patient with presbyopia. The nurse will suspect a change in the macula of the patient's eye in the patient with macular degeneration
How do reminiscence strategies evaluate the memory of an older adult? They produce a positive mood. They reduce the patient's anxiety. They resolve current conflicts by recollecting the past. They allow evaluation of a patient's judgment and general knowledge.
They resolve current conflicts by recollecting the past. . Reminiscence strategies can be used to resolve current conflicts by recollecting past events. These strategies may help the patient to recollect a coping strategy but do not produce a positive mood or reduce the patient's anxiety. Reminiscence strategies are not necessarily helpful in evaluating the patient's judgment and general knowledge.
Which right according to the Dying Person's Bill of Rights would the nurse be aware of when treating terminally ill patients? Select all that apply. One, some, or all responses may be correct. To die alone To be judged To be free from pain To retain individuality To make decisions about care
To be free from pain To retain individuality To make decisions about care The rights include to be free from pain, to retain individuality, and to make decisions about care. According to the Dying Person's Bill of Rights, the person has the right not to die alone; thus the patient should not be left to die alone. According to the Dying Person's Bill of Rights, the patient has the right to not be judged; therefore to be judged is unacceptable.
A patient who received penicillin developed a rash on the right hand. The patient asked the nurse why the rash developed. How would the nurse explain this to the patient? Create his or her own explanation. Inquire why the patient is concerned. Use previous knowledge. Find out which health care provider prescribed the drug.
Use previous knowledge. The nurse has to use previous knowledge before answering the patient's queries. Nurses should not create their own explanations, because these could be wrong and misleading. If the nurse is unable to give an explanation, a senior staff member should be consulted for guidance. The nurse should not ask the patient why the patient is concerned; this could lead to patient withdrawal. Knowing which health care provider prescribed the drug will not help determine the reason for the reaction.
