Exam 3 Flashcards
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority for further assessment and intervention?
a. “I spent my whole life dreaming about retirement, and now I wish I had my job back”
b. “it’s been so stressful for me to have to depend on my son to help around the house
c. “i just heard my friend al died. that’s the third one in 3 months.
d. “i’m struggling with helping out in my community. I just don’t know what I can do”
d. “i’m struggling with helping out in my community. I just don’t know what I can do”
A nurse is admitting an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply.)
a. Do you eat alone or with someone?
b. Do you watch TV while eating your meals?
c. Have you started any new medications int he past 6 months?
d. What foods have you eaten within the past 24 hours?
e. Are you on a fixed income?
a. Do you eat alone or with someone?
c. Have you started any new medications in the past 6 months?
d. What foods have you eaten in the past 24 hours?
e. are you on a fixed income
A nurse is giving a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply.)
a. HPV immunization
b. Pnemonococcal immunization
c. Eye examination
d. Mental health screening
e. Dual energy x-ray absorptimetry (DEXA) scanning
b. Pnemonococcal immunization
c. Eye examination
d. Mental health screening
e. Dual energy x-ray absorptimetry scanning
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply)
a. increase iron intake to prevent anemia
b. decrease fluid intake to prevent urinary incontinence
c. increase calcium intake to prevent osteoporosis
d. limit sodium intake to prevent edema
e. increase fiber intake to prevent constipation
c. increase calcium intake to prevent osteoporosis
d. limit sodium intake to prevent edema
e. increase fiber intake to prevent constipation
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.)
a. skin thickening
b. decreased height
c. increased saliva production
d. nail thickening
e. decreased bladder capacity
b. decreased height
d. nail thickening
e. decreased bladder capacity
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?
A. Allowing the client to function independently will strengthen her muscles and promote healing. B. The client needs to be given privacy at times for self-re ecting and organizing her life.
C. The client’s sense of loss can be lessened through retaining control of certain areas of her life.
D. Performing ADLs is required prior to discharge from an acute care facility.
C. The client’s sense of loss can be lessened through retaining control of certain areas of her life.
A nurse is caring for a client who has stage 4 lung cancer and is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter’s wedding.” Based on Kübler-Ross’ Five Stages of Grief, which stage is the client experiencing?
A. Anger
B. Denial
C. Bargaining D. Acceptance
C. Bargaining
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, “I hate him for leaving me.” Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.)
A. “Would you like me to contact the chaplain to come speak with you?”
B. “You will feel better soon. You have been expecting this for a while now.”
C. “Let’s talk about your children and how they are going to react.”
D. “You know, it is quite normal to feel anger toward your husband at this time.” E. “Tell me more about how you are feeling.”
A. “Would you like me to contact the chaplain to come speak with you?”
D. “You know, it is quite normal to feel anger toward your husband at this time.”
E. “Tell me more about how you are feeling.”
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client’s family is at the bedside and asks the nurse what are anticipated clinical findings at this time. Which of the following is an appropriate response by the nurse?
A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone
D. Decreased muscle tone
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply.)
A. “I will remove the dentures from the body.”
B. “I will make sure the body is lying completely flat.”
C. “I will apply fresh linens and place a clean gown on the body.”
D. “I will remove all equipment from the bedside.”
E. “I will dim the lights in the room.”
C. “I will apply fresh linens and place a clean gown on the body.”
D. “I will remove all equipment from the bedside.”
E. “I will dim the lights in the room.
A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report?
A. The client’s input and output for the shift
B. The client’s blood pressure from the previous day
C. A bone scan that is scheduled for today
D. The medication routine from the medication administration record
C. A bone scan that is scheduled for today
A nurse enters a client’s room and finds him sitting in his chair. He states, “I fell in the shower, but I got myself back up and into my chair.” How should the nurse document this in the client’s chart?
A. The client fell in the shower.
B. The client states he fell in the shower and was able to get himself back into his chair.
C. The nurse should not document this information in the chart because she did not witness the fall.
D. The client fell in the shower but is now resting comfortably.
B. The client states he fell in the shower and was able to get himself back into his chair.
- A nursing instructor is reviewing documentation with a group of nursing students. Which of the following legal guidelines should they follow when documenting in a client’s record? (Select all that apply.)
A. Cover errors with correction fluid, and write in the correct information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
The skin barrier covering a client’s intestinal stula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the current shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist did not ambulate the client today. The client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? (Select all that apply.)
A. The physical therapist did not ambulate the client today.
B. The skin barrier’s seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a “day off” from physical therapy.
D. The wound care nurse will see the client later today.
E. The client ate all the food on her lunch tray.
A. The physical therapist did not ambulate the client today.
B. The skin barrier’s seal stays on in bed but loosens when the client stands.
D. The wound care nurse will see the client later today.
A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)
A. Repeat the details of the prescription back to the provider.
B. Have another nurse listen to the telephone prescription.
C. Obtain the prescriber’s signature on the prescription within 24 hr.
D. Decline the verbal prescription because it is not an emergency situation.
E. Tell the charge nurse that the provider has prescribed morphine by telephone.
A. Repeat the details of the prescription back to the provider.
B. Have another nurse listen to the telephone prescription.
C. Obtain the prescriber’s signature on the prescription within 24 hr.
