Patient Centered Care-PrepU

During an assessment of a patient's functional health pattern, which question by the nurse directly addresses the patient's thyroid function?

"Do you experience fatigue even if you have slept a long time?"

The nurse is teaching a client with HIV how to use a male condom. The client demonstrates understanding of the information when he states which of the following? Select all that apply.

"I should unroll the condom all the way over my erect penis." • "I need to hold the condom by the tip to squeeze out the air before putting it on." • "I should avoid using baby oil or petroleum jelly with a condom."

An Asian American client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had his prescribed medicines. The client believes that eating saffron will keep his blood sugar under control. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?"

The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?

"Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself."

A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to his legs will illicit severe pain. The client is describing which type of pain?

Allodynia

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" The nurse's appropriate response is which of the following?

Apricots, dried peas and beans, dates

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient?

Assisting the patient to turn, cough, and deep breathe every 2 hours

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?

Bank autologous blood.

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Cerebral angiography

A client with a history of respiratory problems tells the nurse that he would like to explore strategies to reduce his risks. He also mentions being currently unemployed and not wanting to pursue costly strategies. What would the nurse emphasize as the single most cost-effective intervention to reduce the risk of developing COPD or slow its progression?

Cessation of smoking

Effective, individualized care that shows respect for the dignity, personal rights, preferences, beliefs, and practices of people receiving care while acknowledging the bias of the caregiver and preventing that bias from interfering with care. This is a definition of?

Culturally competent nursing care

Spina bifida, cerebral palsy, Down syndrome, and muscular dystrophy are all examples of which type of disability?

Developmental

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

A client tells the nurse, ?My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one.? What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

An appropriate nursing intervention for the client following a nuclear scan of the kidney is to:

Encourage high fluid intake.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI is located.

Which of the following is a clinical manifestation of diabetes insipidus?

Excessive thirst

The nurse prepares to auscultate heart sounds. Which nursing interventions would be most effective to assist with this procedure?

Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard.

When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority?

Exploring how the client's feelings affect his/her decision to refuse medication

A harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle is termed which of the following?

Friction rub

A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, "My boyfriend has been beating me up once in a while since I became pregnant, but I cannot bring myself to leave him because I do not have a job and I do not know how I would take care of my other children." What is the priority by the nurse at this time?

Help the client make concrete plans for the safety of herself and her children.

A nurse is preparing to teach a 6 year old with a broken arm and her mother about cast care. Which statement reflects the best teaching plan for these clients?

Include the child in teaching; ask questions of both mother and child.

A patient who had bariatric surgery complains of diarrhea. The nurse recommends which of the following dietary changes?

Increased fiber

For individuals known to be dying by virtue of age and/or diagnoses which of the following signs indicate approaching death?

Increased restlessness

The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?

Increased sensitivity to medications

A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is

Instruct the son about lack of client consent.

The nurse is caring for a Hispanic client who is very ill. The client's spouse has asked to speak with the physician, who makes her rounds between 0900 and 1000 every morning. The nurse tells the spouse to be at the bedside at that time in order to talk with the physician, but the spouse never arrives until afternoon. Knowing that some Hispanic people view time in a wider frame of reference, the appropriate response to this behavior is which of the following?

Make other arrangements with the physician to facilitate a meeting with the spouse.

Which medication should be readily available for patients receiving epidural opioids who are experiencing respiratory depression?

Naloxone

The nurse is providing discharge instructions to a client with unstable angina. The client is ordered Nitrostat 1/150 every 5 minutes as needed for angina. Which side effect, emphasized by the nurse, is common especially with the increased dosage?

Orthostatic hypotension

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:

Oxygen therapy through a non-rebreather mask

Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?

Pancreatic necrosis

A nurse is talking on the phone with a doctor and states, "I am calling you about Mrs. Nye, my client with cancer in room 213." This is an example of what type of language that is important to all people?

People-first

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, ?I have smoked since I was 12 years old. I am not going to stop now.? What is the appropriate response by the nurse?

Please tell me your thoughts about treating this diagnosis.?

The nurse is caring for a patient who communicates via sign language. To promote communication, the nurse should do which of the following?

Provide a sign language interpreter.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety.

The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Reports increased fatigue

The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:

Severe abdominal pain

A client is brought to the mental health center by a police officer for an evaluation because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." Which factor would be most relevant to a decision about this client's disposition?

She seems able to care for herself.

A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which of the following is the most appropriate step for the nurse to take to help the client?

Support the client in developing attainable socialization goals.

A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery?

Surrogate decision maker.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?"The nurse is correct to instruct on the action of which system?

Sympathetic nervous system

The nurse is caring for a patient with TBI (traumatic brain injury). The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F

The client comes to the clinic to obtain the results from the test to determine if he is infected with HIV. The physician informs the client that he has a CD4 cell count of 300 cells/mm3 and a high viral load. What does the nurse anticipate the physician will discuss with the client?

The initiation of antiretroviral therapy

The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso . For which action, made by the nurse aide, would the nurse provide further instruction?

The nurse aide moved the client's head to clean behind the ears.

A nurse is providing teaching to patients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? (Select all that apply.)

The nurse fails to accept that patients have the right to change their minds. • The nurse uses medical jargon frequently when discussing the teaching plan. • The nurse ignores the restrictions of the patient's environment.

The client, an 83-year-old man, is admitted with heart failure. The nurse is aware that education needed prior to discharge includes which of the following?

Try to avoid emotional stress and take part in mild physical stress only.

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Verbal response • Motor response • Eye opening

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?

Widened pulse pressure

The primary goal of nursing care for a client with stress incontinence is to:

decrease the number of incontinence episodes.

A nurse is caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment?

dizziness

A client has had multiple admissions for heart failure. The client is now on continuous oxygen, bedridden, and provided care by his family. The nurse discusses end-of-life preferences with the client. The nurse assesses the client is in the phase of the Trajectory Model of Chronic Illness known as

downward

A home health care nurse develops a client's individualized plan of care during the:

entry phase.

The presence of crystals in synovial fluid obtained from an arthrocentesis is indicative of

gout

A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client:

if he is thinking about hurting himself.

On admission to the hospital, patients are asked if they have a living will or a durable power of attorney. If not, the admitting staff person will provide a sample form to the patient if they want it. The purpose of this inquiry is to determine:

if they have a document describing their wishes for care when they are no longer able to make their own decisions.

The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old's mother is upset because the parent staying with the other child is male and believes the arrangement is violates her social norms. The nurse should:

reassign the children to different rooms.

A nurse who is a practicing Jehovah's Witness is asked by a client whether or not to consent to having a blood transfusion. Which of the following would be the appropriate response by the nurse in this situation?

"It is your opinion that is important. How do you feel about the transfusion?"

A competent client requiring long-term mechanical ventilation privately tells a nurse that he/she wants the ventilator withdrawn. Which response by the nurse is best?

"Tell me how you are feeling."

An Appalachian male has been admitted to the unit for chest pain. A nurse told the family that they could not be with the client. The family became very upset and the client wants to leave. What is the most appropriate cultural response by the charge nurse?

"Would you feel more comfortable with your family with you?"

The nurse is teaching a patient about her rheumatic disease. What statement best helps to explain "autoimmunity"?

"Your symptoms are a result of your body attacking itself."

The nurse is caring for a 48-year-old Native American man hospitalized following an MI who asks to see his medicine man. What would be the nurse's best response to this patient?

Arrange for a visit with the medicine man in the hospital.

The nurse caring for a patient with a dysrhythmia understands that the P wave on an electrocardiogram (ECG) represents what phase of the cardiac cycle?

Atrial depolarization

A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe?

Atropine

Which of the following positions are employed to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis?

Providing intensive insulin therapy

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?

Restricting fluid intake and hydration

A 26-year-old client is returning for diagnostic follow-up. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minutes. What type of dysrhythmia would you expect the cardiologist to diagnose?

Sinus tachycardia

Which of the following populations, now in the majority, is projected to be in the minority by the middle to late 21 century?

caucasion americans

A patient who is an avid runner had an emergency below-the-knee amputation after a motor vehicle accident. The nurse hears a physical therapist tell the patient that she may have to stop running. The nurse attributes this comment as an indication that the physical therapist's frame of reference for caring for patients with disabilities is which of the following?

medical model

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.

that the client has full awareness of the potential complications • that there was adequate disclosure of information • that the client understood the information • that there was voluntary consent on the client's part

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

vomits