Nursing Concepts Exam 4

Taking more than six medications Having cataracts Muscle strength 3/5 bilaterally Incontinence

A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical.

Pathologic impairment of sensory responses

A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?

"Stressors such as illness cause the release of hormones that increase blood sugar."

A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate?

Slow and deepen breathing via use of a positive, repeated word.

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first?

Ask if there is another family member who can help at home while the patient is in the hospital.

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?

Teaching the patient to recognize, reconsider, and reframe irrational thoughts

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations?

"Let's talk about what is going on in your life and then look at possible options."

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response?

His systolic blood pressure has gone from the 140s to the 120s (mm Hg).

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress?

Plan to reinforce and repeat teaching about diabetes management.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take?

Have training sessions to help the staff understand their new responsibilities.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff?

"I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe."

An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following?

"You should see an improvement in the next week or so. Call if this continues."

An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response?

The patient has recently lost her spouse and needed to move in with her daughter.

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint?

Irrigation of the ear

During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure?

24-Hour Functional Ability Questionnaire (24hFAQ)

The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize?

"This tool will help assess recent positive and negative events you are experiencing."

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool?

"Do you use a cane, walker, or wheelchair to ambulate?"

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate?

Functional Activities Questionnaire (FAQ)

The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities?

Healthy individual, volunteers at church, works part-time, takes care of family and house

The nurse is assessing a patient's functional ability. Which patient best demonstrates the definition of functional ability?

Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment

The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment?

Current stressors as perceived by the patient Use of drugs or alcohol Recent weight changes

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment?

Identifying a confidant to share feelings

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy?

Maintaining a safe environment, breathing, maintaining temperature

The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient?

Notify the physician.

The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?

Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function?

"Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle."

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

Identifying the cause of fear

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as which of the following?

Suggest that the patient consider a support group for widows. Suggest that the patient learn stress reduction breathing exercises. Assist the patient in identifying support systems.

The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient?

"Imitation of sounds is the first step in language development, and it is important to identify alterations early."

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?

Suggest use of talking books.

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase?

Increased risk for suicide

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population?

Ask about epigastric pain. Observe for increased appetite. Check for elevated blood glucose levels.

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient?