Comprehensive Flashcards
A 38-year-old client is asking for medication for trouble falling asleep and staying asleep. The client also feels groggy and unrested during the day. What should the nurse assess for as possible etiologies? Select all that apply.
1.
Watching TV while in bed
- Sleeping with smart phone nearby
- Caffeine consumption
- Current medications
- Exercise/activities
- Watching TV while in bed
- Sleeping with smart phone nearby
- Caffeine consumption
- Current medications
A client admitted with pneumonia informs the nurse of a preference for complementary medicine treatment. Which oil could the nurse suggest the family bring in for the client?
- Geranium
- Eucalyptus
- Ylang Ylang
- Peppermint
2.
Eucalyptus
A client is discussing an extended family-related conflict with the nurse and states he or she is tired of the problem and does not participate in family get-togethers because of it. Which ego defense mechanism will the nurse document that the client is using?
- Denial
- Avoidance
- Projection
- Displacement
2.
Avoidance
A client presents to the clinic requesting medication to help him or her sleep. The health-care provider diagnoses the client with insomnia. Which criteria would the nurse expect to be present related to this diagnosis? Select all that apply.
- Happens three times a night
- Happens three days per week
- Happens for at least three months
- Happens when unable to sleep for three hours
- Happens from three causes: caffeine, smoking, or alcohol
- Happens three days per week
- Happens for at least three months
A new nurse is learning how to set up telemetry monitoring for a new admission. Put the steps in the correct order.
.
Expose the client’s chest and shave the hair if dense.
Connect the lead wires to the transmitter.
Clean the client’s skin with an alcohol pad.
Remove the electrode backing.
Insert a new battery into the transmitter.
Attach the lead wires to the electrodes.
Turn on the transmitter.
Apply the electrodes to the sites.
Place the transmitter in the pouch and the pouch strings around the client’s neck.
Secure the monitoring equipment.
First, the nurse will insert a new battery into the transmitter and turn it on. The nurse should then connect the lead wires to the transmitter. Then the nurse exposes the client’s chest and shaves the hair if it is thick or dense. The nurse cleans the client’s skin with an alcohol pad, removes the electrode backing, and attaches the lead wires to the electrodes. The nurse applies the electrodes to the sites, secures the monitoring equipment, and places the transmitter in the pouch and the pouch strings around the client’s neck.
A nurse is assessing a client with cardiac pain. What is the difference between cardiac pain and pleuritic pain? Select all that apply.
- Pleuritic pain is unrelieved with nitrates.
- Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety.
- Pleuritic pain is the result of a pulmonary emboli.
- Cardiac pain typically does not change with inhalation or exhalation.
- Pleuritic pain is diagnosed with cholesterol, lipid panel, C-reactive protein, and glucose testing.
- Pleuritic pain is unrelieved with nitrates.
- Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety.
- Cardiac pain typically does not change with inhalation or exhalation.
A nurse is assessing an older client for orthostatic hypotension. What receptors would respond to a client’s lowering blood pressures?
- Chemoreceptors
- Thermoreceptors
- Baroreceptors
- Photoreceptors
3.
Baroreceptors
A nurse is explaining to a client the differences between physiological and psychological responses to anxiety. Which statements indicate the client understands the physiological indicators? Select all that apply.1.
“My heart feels like it’s racing all the time.”
- “I don’t know why my speech is so rapid.”
- “I wish I could have something for this diarrhea.”
- “My wife complains how irritable I am all the time.”
- “When I drive in the car, I start to hyperventilate.”
- “I have a difficult time falling asleep.”
“My heart feels like it’s racing all the time.”
- “I wish I could have something for this diarrhea.”
- “When I drive in the car, I start to hyperventilate.”
- “I have a difficult time falling asleep.”
A nurse is preparing to give a client an injection. As the nurse begins to give the injection, the client winces and withdraws. Which factor affecting sensory response does this demonstrate?
1.
Contrast
- Intensity
- Adaptation
- Previous experience
4.
Previous experience
A nurse is preparing to perform a focused assessment of a client’s respiratory system. Which aspects should the nurse include in the assessment? Select all that apply.
1.
Rate
- Edema
- Body position
- Capillary refill
- Breath sounds
- Use of accessory muscles
- Rate
- Body position
- Breath sounds
- Use of accessory muscles
A nurse is teaching a client how to promote venous circulation. Which statements by the client indicates understanding of the teaching? Select all that apply.
- “I will keep my legs elevated when I am sitting in the recliner.”
- “I will take a walk around the block in the morning and afternoon.”
- “I will only be able to perform range-of-motion exercises once per week”
- “It’s ok if I sit with my legs crossed in the car.”
- “I will drink at least six 8-ounce glasses of water every day.”
6. “I will attend a smoking cessation class at the YMCA.”
- “I will keep my legs elevated when I am sitting in the recliner.”
- “I will take a walk around the block in the morning and afternoon.”
- “I will drink at least six 8-ounce glasses of water every day.”
6. “I will attend a smoking cessation class at the YMCA.”
A nurse notes a history of peripheral neuropathy in the medical record of a client. What should the nurse include in the assessment of this client? Select all that apply.
- Deep diffuse pain
- Numbness of the feet
- Cramping and achiness
- Feeling of pins and needles
- Itching on the soles of the feet
- Numbness of the feet
- Feeling of pins and needles
- Itching on the soles of the feet
According to the gate-control theory of pain, which type of fibers inhibit the client’s perception of pain?1.
Mu fibers
- A-delta fibers
- Alpha fibers
- Sigma fibers
2.
A-delta fibers
Clients who experience anxiety may use defense mechanisms to cope. The nurse knows that a common defense mechanism is denial. What is denial?
- Refusing to acknowledge reality or associated feelings
- Transferring feelings from one object or person to another
- Attempting to pattern or resemble the personality of an admired person
- Attributing one’s own unacceptable feelings and thoughts to others
1.
Refusing to acknowledge reality or associated feelings
Conditions that beta blockers treat
- Angina
- Congestive heart failure
- Acute myocardial infarction
he nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen?
- Inflammatory phase
- Maturation phase
- Proliferative phase
- Tertiary phase
1.
Inflammatory phase
How is homeostasis defined?
- When a person makes changes to cope with a situation
- A disturbance in a person’s normal balanced state
- When a person’s internal and external equilibria are maintained
- Adapting to the changes and stressors of illness and caregiving
3.
When a person’s internal and external equilibria are maintained
How often should the nurse provide tracheostomy care?
- Every 8 hours
- Every 24 hours
- Every other day
- Every week
1.
Every 8 hours
In which sleep stage would a client’s EEG show beta waves?
- Drowsy stage
- In periods of wakefulness
- Earlier phase of NREM
- When transitioning to deep sleep
2.
In periods of wakefulness
In which way is pain positive?
- Keeps the person having pain more alert
- Warns of bodily injury
- May diminish over time
- May interfere with quality of life
2.
Warns of bodily injury
Place in order the neuroendocrine responses that occur during the fight-or-flight response?
1.
2.
3.
4.
5.
6.
Thyroid-stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy.
Corticotropin-releasing hormone (CRH) is released from the hypothalamus.
Endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well-being and reducing pain.
Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
Antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water.
Corticotropin-releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH).
Corticotropin-releasing hormone (CRH) is released from the hypothalamus.
Corticotropin-releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH).
Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
Antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water.
Endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well-being and reducing pain.
Thyroid-stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy.
The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use. Which medication may have caused this sensory loss?
- Lisinopril (Zestril)
- Vinblastine (Velban)
- Atorvastatin (Lipitor)
- Gentamicin (Garamycin)
4.
Gentamicin (Garamycin)
The nurse is performing passive range of motion for a client with osteoarthritis and feels a grating sound in the left knee. How would the nurse document this finding?
- Edema
- Friction
- Shearing
- Crepitus
4.
Crepitus
The nurse is preparing to interview a 25-year-old client who reports having problems at work. Which skills should the nurse incorporate into the interview to promote open communication with the client? Select All That Apply.
- Allowing emotions to show
- Maintaining the focus on the client
- Incorporating open-ended questions
- Being respectful of cultural details
- Being cognizant of self-imposed biases
- Permitting the client to control the interview direction
- Maintaining the focus on the client
- Incorporating open-ended questions
- Being respectful of cultural details
- Being cognizant of self-imposed biases
- Permitting the client to control the interview direction
The nurse is reviewing the structures of the heart. Which part is the pericardium?
- Two thin-walled muscles that receive blood into the heart
- A sac of connective tissue that encases the heart
- Two thick-walled muscles that pump blood out of the heart
- The nerve tissue that acts as the pacemaker
2.
A sac of connective tissue that encases the heart
The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity. Which clinical manifestations should the nurse instruct the family to report? Select all that apply.
- Withdrawal
- Depression
- Aggression
- Combative
- Hallucinations
- Social isolation
- Withdrawal
- Depression
- Hallucinations
- Social isolation