FADAVIS.com quiz questions

Question 1

What is an integrated plan of care?

Answer 1

Integrated plans of care (IPOCs) are a combined charting and care plan form. An IPOC maps out day-by-day patient goals, outcomes, interventions, and treatments for a specific diagnosis or condition from admission to discharge. Lab work, diagnostic testing, medications, and therapies are all included in the pathway, as well as standardized interventions captured in the plan.

Question 2

You are assessing a client’s risk for sensory deprivation. Which of the following situations would increase the client’s risk?

SELECT ALL THAT APPLY.

1) Being on a sedative
2) Having a traumatic brain injury
3) Being physically active
4) Having a hearing impairment
5) Working in a busy airport
6) Being a non-English-speaking visitor to the United States

Answer 2

Feedback 1: Impaired sensory reception (e.g., neurological injury, dementia, depression, sleep deprivation, sensory losses, and central nervous system depressant medications) is a risk factor for sensory deprivation.

Feedback 2: Inability to transmit or process stimuli as a result of a nerve or brain injury is a risk factor for sensory deprivation.

Feedback 3: Restricted mobility, not being physically active, is a risk factor for sensory deprivation.

Feedback 4: Sensory deficits (e.g., vision, hearing) are risk factors for sensory deprivation.

Feedback 5: A nonstimulating, monotonous environment is a risk factor for sensory deprivation. A busy airport would be a stimulating environment.

Feedback 6: Being from a different culture and unable to interpret received cues is a risk factor for sensory deprivation.

Question 3

4. As you prepare to take a client’s blood pressure, you reach back and without looking find the stethoscope hanging on the wall behind you, grab it, and place the ear pieces in your ears. Which of the following receptors allowed you to perform this action?
   1) Mechanoreceptors
   2) Thermoreceptors
   3) Proprioceptors
   4) Chemoreceptors

Answer 3

3) Proprioceptors

Question 4

5. After giving a client the nursing diagnosis of Risk for Falls related to Alzheimer’s disease, you write an individualized goal to address this diagnosis. Which of the following would be the most appropriate goal for this client?
   1) Client will not experience a fall while in the hospital.
   2) Client will explain several strategies for preventing falls while in the hospital.
   3) Client will demonstrate clear and focused thinking and thus will avoid falling while in the hospital.
   4) Client will be able to move independently around her room without falling.

Answer 4

1) Client will not experience a fall while in the hospital.

Question 5

Following allergy testing with a child, you find that she is allergic to cockroaches. This finding means that the child is at greater risk for which of the following?

1) Severe asthma
2) Rabies
3) Lung cancer
4) Fungal infection

Answer 5

1) Severe asthma

Question 6

You are caring for a client with macular degeneration who lives alone. Which of the following nursing diagnoses would be most appropriate for this client?

1) Risk for Falls r/t visual impairment
2) Risk for Injury r/t reduced tactile sensation
3) Bathing Self-Care Deficit r/t kinesthetic impairment
4) Deficient Diversional Activity r/t reluctance to be in social situations because of hearing impairment

Answer 6

1) Risk for Falls r/t visual impairment

Question 7

You are caring for an older patient in the hospital who is at risk for falling. The client is cognitively normal but lacks coordination. Which of the following are interventions you should take to help prevent the client from falling?

SELECT ALL THAT APPLY.

1) Use quarter-length siderails on the patient’s bed.
2) Keep the bed in a low position.
3) Provide nonskid slippers.
4) Keep water, urinal, bedpan, and tissues out of reach so that the patient must have assistance to get them.
5) Encourage the patient to move to and from the bathroom independently, to build confidence.
6) Provide a night light.

Answer 7

Feedback 1: A half- or quarter-length upper siderail can be an aid to independence if it is used by the patient for the purpose of getting into and out of bed. Similarly, split rails are not considered restraints if a client requests them to feel more secure. The use of siderails can help prevent the patient from falling out of bed.

Feedback 2: Keep the bed in a low position, except when giving care, with wheels locked.

Feedback 3: Provide nonskid slippers to give the patient better traction when walking.

Feedback 6: Provide a night light to facilitate walking in the dark.

Question 8

You have decided that as a last resort you must apply physical restraints to a client who is at risk of injuring himself and healthcare team members. Which of the following actions must you take?

SELECT ALL THAT APPLY.

1) Obtain a medical order before restraining.
2) Secure restraints in a way that allows for quick release.
3) Check restraints every 2 hours.
4) Remind prescriber to reassess and reorder the restraints every week, as needed.
5) Ensure that the restraints do not impair circulation or tissue integrity.
6) Release restraints and assess every 8 hours.

Answer 8

Feedback 1: Obtain a medical order before restraining, except in an emergency.

Feedback 2: Secure restraints in a way that allows for quick release.

Feedback 3: Check restraints every 30 minutes, not every 2 hours.

Feedback 4: A prescriber must reassess and reorder the restraints every 24 hours, not every week.

Feedback 5: Ensure that restraints do not impair circulation or tissue integrity.

Feedback 6: Release restraints and assess every 2 hours, not every 8 hours (more often for behavioral restraints).

Question 9

One of your clients has recently taken a job in road construction. Which of the following are adverse health effects associated with substantial exposure to loud noises that you should warn the client about, to encourage him to use hearing protection?

SELECT ALL THAT APPLY.

1) Respiratory disease
2) Hearing loss
3) Stress
4) Cancer
5) Elevated blood pressure
6) Loss of sleep

Answer 9

Feedback 1: Respiratory disease is associated with smoking, not with substantial exposure to loud noises.

Feedback 2: Hearing loss is associated with substantial exposure to loud noises.

Feedback 3: Stress is associated with substantial exposure to loud noises.

Feedback 4: Cancer is associated with smoking, not substantial exposure to loud noises.

Feedback 5: Elevated blood pressure is associated with substantial exposure to loud noises.

Feedback 6: Loss of sleep is associated with substantial exposure to loud noises.

Question 10

You hand a form to a middle-aged client to sign, and the client squints at it, holds it at arm’s length, and then says, “Hold on—I need to get my reading glasses to see this. My vision’s just getting terrible these days.” Which of the following visual deficits is this client most likely experiencing?

1) Myopia
2) Hyperopia
3) Presbyopia
4) Glaucoma

Answer 10

Presbyopia is a change in vision associated with aging. The lens becomes less elastic and less able to accommodate to near objects. If you’re older than age 40 years, there’s a good chance you may be experiencing this problem.

Question 11

You are documenting a patient’s prescriptions on a medication administration record. You need to record a pain medication that was prescribed to be given to the patient on an “as needed” basis. Which of the following terms should you use to refer to this type of medication?

1) Unscheduled
2) PRN
3) Stat
4) Single-order

Answer 11

2) PRN
The Latin term pro re nata is abbreviated as prn, or as needed. Medications that are prn are given only when the patient meets certain conditions that were established in the medication prescription. Typically, medications are prescribed prn for relief of pain, fever, nausea, and constipation.

Question 12

You are teaching a group of older adults in a senior center about the hazards of carbon monoxide poisoning and methods to prevent it. Which of the following interventions should you mention related to this hazard?

1) Avoid smoking in the home.
2) Avoid exposing oxygen administration equipment to an open flame.
3) Avoid contact with clothing contaminated by toxins from industrial workplaces.
4) Avoid using your gas range to heat your home.

Answer 12

4) Avoid using your gas range to heat your home.

Carbon monoxide (CO) is a colorless, tasteless, odorless, toxic gas. Many CO deaths occur during cold weather among older adults and the poor who seek unconventional heat sources (e.g., gas ranges and ovens) to stay warm.

Question 13

You work in a hospital in which clients typically have a large team of interdisciplinary practitioners providing care for them, many of whom do not have much time to document findings. Which type of health record would you advocate for in this setting?

1) Source-oriented record
2) Problem-oriented record
3) Charting by exception
4) Patient-oriented record

Answer 13

1) Source-oriented record

Patients in hospitals and long-term care facilities receive care from a variety of disciplines, so these institutions commonly use source-oriented records. Members of each discipline record their findings in a separately labeled section of the chart.

Question 14

It is the end of the shift, and you are preparing to give a handoff report to the receiving nurse. Which of the following is the primary rationale for this action?

1) Backup procedure in case electronic records are lost
2) Opportunity to speculate on diagnoses not mentioned in written documentation
3) Continuity of care for patient
4) Build rapport with other nursing staff

Answer 14

3) Continuity of care for patient

The purpose of giving an oral report is to maintain continuity of care.

Question 15

You provide home nursing care to an older client who lives alone in a cluttered apartment and who has macular degeneration. You are concerned that the client may fall while at home alone. Which of the following nursing diagnoses would be most appropriate?

1) Risk for Falls related to poor vision and a cluttered home environment
2) Risk for falls related to environmental and physical factors
3) Risk for Falls related to a sensory problem and environment
4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration

Answer 15

4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration

Keep in mind that you must state specific etiologies for each individual—not just general ones such as “environmental hazards.” In this case, the etiologies are clearly specified.

Question 16

You are preparing to give a handoff report to the receiving nurse. During the handoff you would like to show the receiving nurse some lesions that have appeared on the patient’s arm. Which type of report would be best for you to perform?

1) Bedside report
2) Face-to-face oral report
3) Audio-recorded report
4) Standardized report

Answer 16

1) Bedside report

A bedside report, sometimes known as “walking rounds,” allows you to observe important aspects of care, such as patient appearance, intravenous pumps, and wounds.

Question 17

You are caring for a client with severely limited vision. Which of the following interventions should you make?

SELECT ALL THAT APPLY.

1) Provide an uncluttered environment.
2) Provide closed-caption television.
3) Consider conversion to text-telephone service.
4) Consider books on tape or in Braille for the client.
5) Avoid distracting the client’s guide dog.
6) Keep the bed in a high position.

Answer 17

Feedback 1: For clients with severely limited vision, provide an uncluttered environment and do not rearrange furniture.

Feedback 2: For clients with a hearing deficit, not severely limited vision, provide closed-caption television.

Feedback 3: For clients with a hearing deficit, not severely limited vision, consider conversion to text-telephone service.

Feedback 4: For clients with severely limited vision, consider books on tape or in Braille.

Feedback 5: For clients with severely limited vision, avoid distracting the client’s guide dog.

Feedback 6: For clients with severely limited vision, keep the bed in a low, not high, position.

Question 18

You have recently begun a job as a home health nurse. Which of the following forms will you most likely need for documenting client data in this setting?

2) Occurrence report
3) Nursing admission data form
4) Flowsheet

Answer 18

1) Outcome and assessment information set (OASIS)

The most commonly used paper home health documentation form is known as OASIS—the Outcome and Assessment Information Set.

Question 19

You are assessing a client’s level of consciousness. You begin by speaking to the client, but the client does not respond. Which of the following should you do next in your assessment?

1) Wave at the client to get his attention.
2) Pass smelling salts beneath the client’s nose.
3) Tap on the client’s hand.
4) Shout the client’s name.

Answer 19

3) Tap on the client’s hand.

An alert client will respond to auditory stimuli. If the client does not respond, progress to tactile and then painful stimuli.

Question 20

You are caring for an older client with Alzheimer’s disease. You are concerned about this client getting out of bed unassisted and falling. Which of the following would be the best intervention to prevent this from occurring?

1) Install full-length siderails on the client’s bed and raise them all the way up.
2) Apply a cloth vest restraint to the client.
3) Use a bed alarm with the client and conduct hourly rounds to observe her.
4) Explain the risk of falling to the client and ask her to call for assistance when she needs to get up.

Answer 20

3) Use a bed alarm with the client and conduct hourly rounds to observe her.

Ambularms and bed alarms are an alternative for restraints with patients who climb out of bed and are in danger of falling. Understand that bed alarms do not prevent falls by themselves; they are used to improve the timeliness of staff response. Patients who are at risk for falls require increased observation and surveillance.

Question 21

You are performing an assessment of a patient and recording normal and abnormal findings by body system. Which form should you use for this purpose?

1) Intake and output records
2) Discharge summary
3) Flowsheet
4) Checklist

Answer 21

4) Checklist

Assessments and care may also be recorded on paper and electronic checklists. Common normal and abnormal findings are usually organized according to body systems.

Question 22

You are selecting a charting format to use for documenting patient data. You are considering using a narrative chart entry. Which of the following would be the advantage of such a format?

1) Organized
2) Useful for constructing a timeline of events
3) Time saving
4) Readily identifies problems and trends

Answer 22

2) Useful for constructing a timeline of events

Narrative charting is especially useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations.

Question 23

You are using the Glasgow Coma Scale to assess a client’s level of consciousness (LOC). Which of the following responses to stimuli does this scale assess?

SELECT ALL THAT APPLY.

1) Brainstem reflexes
2) Eye responses
3) Respirations
4) Motor responses
5) Verbal responses
6) Heart rate responses

Answer 23

Feedback 1: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.

Feedback 2: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.

Feedback 3: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.

Feedback 4: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.

Feedback 5: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.

Feedback 6: The Glasgow Coma Scale does not assess for heart rate responses.

Question 24

A child has just been brought into the emergency room for suspected poisoning. Which of the following interventions should you most expect to be ordered?

1) Administering ipecac syrup to induce vomiting
2) Administering activated charcoal
3) Mechanically inducing vomiting by triggering the child’s gag reflex
4) Performing the Heimlich maneuver

Answer 24

2) Administering activated charcoal

For most poisonings, the most effective intervention is professional administration of activated charcoal orally or via gastric tube.

Question 25

You work as a nurse in a long-term care facility. Which form are you required by federal law to use when evaluating all residents within 14 days of admission? 1) Outcome and assessment information set 2) Minimum data set for resident assessment and care screening 3) Nursing admission data form 4) Intake and output records

Answer 25

2) Minimum data set for resident assessment and care screening All clients in long-term care facilities must have a comprehensive assessment at admission. Federal law requires that a resident be evaluated using the Minimum Data Set for Resident Assessment and Care Screening within 14 days of admission.

Question 26

You work in small community clinic in a developing country in which the physician is considering upgrading from a paper health record to an electronic health record system. She asks for your opinion. Which of the following circumstances would cause you to recommend sticking with the paper record system? SELECT ALL THAT APPLY. 1) The region in which the clinic is located has frequent power outages. 2) The clinic has little funding. 3) The physician would like to increase communication and collaboration with healthcare professionals around the region and around the world. 4) The physician would like to decrease the time spent charting. 5) The staff would like to reduce the occurrence of medical errors in charting. 6) Not all of the staff are computer literate.

Answer 26

Feedback 1: An advantage of a paper health record system is that there is no downtime for system changes or power outages. Because the clinic has frequent power outages, an electronic health record may not be the best choice. Feedback 2: A disadvantage of electronic health record systems is that they are expensive. The clinic may not have enough funding to support one. Feedback 3: An advantage of electronic health record systems is that communication is improved among healthcare providers—not only in the facility itself, but also regionally and even globally. Feedback 4: An advantage of electronic health record systems is that nurses spend up to 25% less time charting. Feedback 5: An advantage of electronic health record systems is that medical errors are minimized by programmed alerts that are automatically displayed when a care provider takes an action that could be harmful. Feedback 6: An advantage of an existing paper record system is that care providers are comfortable with it because it is familiar. There is little "learning curve."

Question 27

You are in a restaurant when you see a diner having difficulty breathing. Which of the following is the first thing you should do? 1) Perform the Heimlich maneuver. 2) Perform the choking rescue maneuver. 3) Ask the person, "Are you choking?" 4) Have someone call 911.

Answer 27

3) Ask the person, "Are you choking?" If you suspect airway obstruction in an adult, determine whether the victim is able to speak or cough forcefully (other signs include noisy breathing, loss of consciousness, and dusky skin, lips, and nail beds). Ask, "Are you choking?"

Question 28

You are caring for a 12-year-old boy with autism who was recently admitted to the hospital. His mother looks worried, and when you ask her what's wrong, she says, "His senses get overwhelmed easily, and there's so much going on here." Which of the following are signs of sensory overload, which you should observe for in this client? SELECT ALL THAT APPLY. 1) Depression 2) Preoccupation with heart palpitations 3) Anxiety 4) Inability to concentrate 5) Restlessness 6) Delusions

Answer 28

Feedback 1: Depression is a sign of sensory deprivation, not overload. Feedback 2: Preoccupation with somatic complaints, such as heart palpitations, is a sign of sensory deprivation, not overload. Feedback 3: Anxiety is a sign of sensory overload. Feedback 4: Inability to concentrate is a sign of sensory overload. Feedback 5: Restlessness is a sign of sensory overload. Feedback 6: Delusions are a sign of sensory deprivation, not overload.

Question 29

Below are the steps for performing an otic irrigation on an adult client. Put them in the correct order. Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation. Continue irrigating until the canal is clean. Perform an otoscopic examination. Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear. Place a cotton ball loosely in the outer ear. Place the tip of the nozzle (or syringe) into the entrance of the ear canal, and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the client's head. Warm the irrigating solution to body temperature. Straighten the ear canal by pulling up and back on the pinna.

Answer 29

The steps for performing otic irrigation on an adult client are as follows: 1. Warm the irrigating solution to body temperature. 2. Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear. 3. Straighten the ear canal by pulling up and back on the pinna. 4. Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation. 5. Place the tip of the nozzle (or syringe) into the entrance of the ear canal, and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the client's head. 6. Continue irrigating until the canal is clean. 7. Perform an otoscopic examination. 8. Place a cotton ball loosely in the outer ear.

Question 30

``` Below are the top six causes of accidental death. Put them in the correct order, from the most prevalent cause to the least prevalent cause of the six. Fires Falls Motor vehicle accidents Drowning Firearms Poisoning ```

Answer 30

``` Poisoning motor vehicle accidents firearms falls drowning fires ```

Question 31

You are completing documentation for a client you just visited. Which of the following are examples of proper rationale for documenting information about the client? SELECT ALL THAT APPLY. 1) To communicate with the client's physical therapist regarding progress with improving leg strength 2) To communicate to another nurse to observe for Risk of Imbalanced Nutrition in this client 3) To jot down the names of several good books the client recommended to you 4) To allow the client's physician to plan and evaluate a medication protocol for the client 5) To share with the client's friends and family the client's current health status 6) To allow the client's insurance company to determine the cost of care

Answer 31

Feedback 1: Members of the interdisciplinary team use the health record to communicate about the patient's status and care. Feedback 2: Communication promotes continuity of care by allowing you to inform other nurses of a nursing diagnosis for the client. Feedback 3: Including the names of books the client has recommended to you in your documentation would not be appropriate, as these forms are formal and legal. Feedback 4: Documentation enables physicians, nurses, and other healthcare professionals to plan and evaluate treatment and monitor health status over time. Feedback 5: Patients' health information is protected by federal law (HIPAA) and should be kept private, unless the patient has provided written permission to share the information with someone. Feedback 6: Insurance companies, government and third-party payers, budget managers, and organization billing staff use client health records to determine the cost of care.

Question 32

You are performing a focused physical examination of a client with diabetes. Which of the following sensory deficits, associated with this client's condition, should concern you most? 1) Blindness 2) Hearing impairment 3) Dyskinesia 4) Anosmia

Answer 32

1) Blindness Some diseases affect specific sensory organs. For example, diabetic retinopathy is the leading cause of blindness among adults aged 20 to 74 years.

Question 33

Which of the following are "never" events—events that can cause serious injury or death to a patient and should never happen in a hospital? SELECT ALL THAT APPLY. 1) Myocardial infarction resulting from atherosclerosis 2) A surgical sponge left in a patient after surgery 3) Anaphylactic response to latex gloves 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints

Answer 33

Feedback 1: A myocardial infarction resulting from atherosclerosis is not a never event because it is not an event that can be prevented by healthcare staff. Feedback 2: A foreign object (such as a sponge) left in patients after surgery is a never event. Feedback 3: Anaphylactic response to latex gloves is not a never event. Although it should certainly be prevented in patients with known latex allergies, it cannot be prevented when the patient is unaware that he or she has such an allergy or in cases in which the patient fails to communicate the presence of the allergy to healthcare staff. Feedback 4: Administering the wrong type of blood is a never event. Feedback 5: Severe pressure ulcers are a never event. Feedback 6: Injuries from restraints are a never event.

Question 34

You are caring for a client who is at risk for sensory deprivation. Which of the following interventions should you make? SELECT ALL THAT APPLY. 1) Tape some artwork on the wall that the client's granddaughter made for her. 2) Clean the client's eyeglasses and encourage her to wear them when awake. 3) Turn off the television. 4) Offer the client a back rub. 5) Dim the lights in the room. 6) Remove fresh flowers or other heavily scented items from the room.

Answer 34

Feedback 1: For visual stimulation, put artwork on the walls, furnish colorful pajamas and robes, and place pictures or flowers where the patient can see them. Feedback 2: For visual stimulation, help the patient with glasses to apply them whenever she is not sleeping. Make sure eyeglasses are clean and in good repair. This will allow the patient to receive available stimuli. Feedback 3: Turning off the television reduces visual and auditory stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation. Feedback 4: To provide tactile stimulation, you may want to hold a patient's hand while talking or provide a back rub with morning and bedtime care. Feedback 5: Dimming the lights in the room reduces visual stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation. Feedback 6: Removing fresh flowers or other heavily scented items from the room reduces olfactory stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation.

Question 35

You are working with a new nurse who complains about the constant beeping of a patient's heart monitor. She says to you, "How do you stand hearing that all day long?" You reply, "I don't even notice it anymore unless there is an unexpected change." Which of the following factors is most affecting your response to the beeping in this case? 1) Intensity 2) Contrast 3) Adaptation 4) Previous experience

Answer 35

3) Adaptation Often we take stimuli for granted. Recall your first clinical experience. Did you notice the noise and activity on the unit? Nurses become accustomed to the noise, lights, activity, and even alarms and are able to "tune them out." These stimuli are new to many patients, so they notice them and may have difficulty resting.

Question 36

You are providing safety promotion counseling to the mother of a 2-year-old. Which of the following should you warn her is the leading cause of death in children her child's age? 1) Motor vehicle accidents 2) Drowning 3) Poisoning 4) Homicide

Answer 36

2) Drowning Drowning is the leading cause of death for children aged 1 to 4 years.

Question 37

In accessing patient information via an electronic health record (EHR), which of the following safeguards should you follow to maintain confidentiality and data security? SELECT ALL THAT APPLY. 1) When moving away from an open EHR, close the screen and log out. 2) Use your birth date or Social Security number as your password. 3) Change your password at regular intervals. 4) Share your username and password only with the other nurses on your shift. 5) Do not leave patient data displayed on the screen where others can see it. 6) Never access client health records that you have no professional reason to view.

Answer 37

Feedback 1: When moving away from an open EHR, close the screen and log out. Feedback 2: Create a secure password—not something obvious, such as your birth date, Social Security number, or family members' names. Feedback 3: Change your password at regular intervals even if your organization does not require it. Feedback 4: Do not share your personal username or password with anyone. Feedback 5: Do not leave patient data displayed on the screen where others can see it. Feedback 6: Never access client health records that you have no professional reason to view.

Question 38

``` Below are the components of a popular format for writing nursing progress notes. Put them in the correct order. Revision Objective data Subjective data Interventions Assessment Plan Evaluation ```

Answer 38

The SOAP(IER) format for nursing and other progress notes is as follows: 1. subjective data, 2. objective data, 3. assessment, 4. plan, 5. interventions, 6. evaluation, and 7. revision.

Question 39

You are charting nursing progress notes in SOAP format. Which of the following abbreviation guidelines should you use? SELECT ALL THAT APPLY. 1) Abbreviate all drug names. 2) Write out "greater than" or "less than" rather than using the ">" or "

Answer 39

Feedback 1: Write drug names in full rather than using abbreviations. Feedback 2: Write out "greater than" or "less than" rather than using the ">" or "

Question 40

You are conversing with a 13-year-old client while reviewing his health history before a physical examination. The client mentions to you that he went shooting with his father last weekend. After listening to his story, you ask him whether he knows the rules for safe gun handling. He stammers a minute and then tells you he can't remember them. Which of the following rules should you tell him? SELECT ALL THAT APPLY. 1) Keep your finger on the trigger until you are ready to shoot. 2) Always keep the gun pointed in a safe direction. 3) Assume that a gun is unloaded until you have checked the chamber. 4) Always keep the gun unloaded until ready to use it. 5) Before cleaning a gun make sure that it is loaded. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.

Answer 40

Feedback 1: Never put your finger on the trigger until you are ready to shoot. Feedback 2: Always keep the gun pointed in a safe direction so that even if it were to go off it would not cause injury or damage. Feedback 3: Always assume that a gun is loaded, not unloaded, until you have checked the chamber. Feedback 4: Always keep the gun unloaded until ready to use it. Feedback 5: Before cleaning a gun, make absolutely sure that it is unloaded, not loaded. Feedback 6: If you do not know how to open the gun and inspect the chamber(s), leave it alone and get help from someone who does.

Question 41

You are caring for a client in the hospital who appears to have little interest in eating. When you ask her why she doesn't eat much, she tells you, "Ever since I started this medication, everything just tastes bland to me." The client also complains of having a dry mouth. Which of the following conditions is most likely impairing the client's sense of taste? 1) Anosmia 2) Presbycusis 3) Strabismus 4) Xerostomia

Answer 41

4) Xerostomia Impaired taste most commonly results from xerostomia (excessively dry mouth), which may be caused by medications, decreased saliva production, inadequate fluid intake, poor nutrition, or poor oral hygiene.

Question 42

You are preparing to use the Morse fall scale to assess a client's risk for falls. Which of the following factors does this scale assess for in the client? SELECT ALL THAT APPLY. 1) History of falling 2) Age 3) Gender 4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status

Answer 42

Feedback 1: History of falling is a factor assessed for in the Morse fall scale. Feedback 2: Age is not a factor assessed for in the Morse fall scale. The Get Up and Go fall assessment is used for routine assessment of all older adults. Feedback 3: Gender is not a factor assessed for in the Morse fall scale. Feedback 4: The presence of more than one medical diagnosis is a factor assessed for in the Morse fall scale. Feedback 5: Use of ambulatory aids, such as crutches or a walker, is a factor assessed for in the Morse fall scale. Feedback 6: Mental status (e.g., disoriented, forgetful) is a factor assessed for in the Morse fall scale.

Question 43

While you are performing a focused nursing assessment of a patient's hearing, he mentions that lately he has begun to hear a ringing sound in his ears at night when he lies down to sleep. Which of the following hearing deficits is this client most likely experiencing? 1) Presbycusis 2) Tinnitus 3) Nerve deafness 4) Otitis media

Answer 43

Tinnitus is a term used to describe ringing in the ears. Most tinnitus comes from damage to the microscopic endings of the nerve in the inner ear, for example, trauma, turbulent blood flow, hypertension, ear infection, medications, otosclerosis, or arthritic changes of the bones of the ear.

Question 44

As you are walking along the sidewalk, you feel your cell phone vibrating in your pocket. Which of the following receptors allow you to receive this stimulus? 1) Mechanoreceptors 2) Thermoreceptors 3) Proprioceptors 4) Chemoreceptors

Answer 44

Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

Question 45

As you are bathing a client, you notice some breaks in the skin on the back. When you ask the client about it, he says, "Something has been making me itch back there. I've probably just scratched it too hard." Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne

Answer 45

1) Pruritus Pruritus (itching) may lead to scratching and breaks in the skin.

Question 46

You are preparing to bathe an older adult who is incontinent and who is unable to bathe himself. As you remove his diaper, you see that his perineal area is covered with feces. Which type of bath would be most appropriate to give this client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath

Answer 46

4) Basin and water bath A basin and water bath is a modification of the bed bath, in which you use a disposable basin with water or pH-balanced, no-rinse soap, lotion, and washcloths to provide a bath if the patient refuses the prepackaged bath or if the patient is grossly soiled (i.e., large amounts of blood or feces).

Question 47

You are teaching a workshop on providing culturally competent care to a class of fellow nurses at your hospital. One nurse asks, "Why do we need to learn this?" Which of the following responses should you give? SELECT ALL THAT APPLY. 1) "Our population is diverse and becoming more so all the time." 2) "Minority groups experience higher rates of illness, and we need to be aware of that." 3) "Disparities in the quality of care among racial groups are common, and we need to work to eliminate them." 4) "Nursing care that is appropriate for the dominant cultural group may be ineffective and inappropriate for people of other cultures." 5) "Learning cultural competence will prevent discrimination lawsuits against the hospital." 6) "Many racial and ethnic groups lack sufficient access to preventive health care."

Answer 47

Feedback 1: correct. In your practice, you will almost certainly care for patients who are not from your culture. The United States is a multicultural society. We continue to see a trend of increasing immigration from Asian and Spanish-speaking nations. Feedback 2: correct. Minority groups experience higher rates of illness and death and, in general, poorer health status compared with the white, non-Hispanic population. Feedback 3: correct. Disparities in quality of care among racial groups are common. Feedback 4: correct. Nursing care that is appropriate for the dominant cultural group may be ineffective and inappropriate for people who have a different cultural heritage. Feedback 5: wrong. Although it may be true that practicing cultural competence might help prevent lawsuits against the hospital, it would not prevent them altogether. Moreover, this is not a primary reason for such practices. Feedback 6: correct. Lack of access to preventive health care and language barriers can account for differences in the health status of racial and ethnic groups.

Question 48

You are investigating what vulnerable populations exist in your city. Which of the following are groups that are likely to be vulnerable populations in the United States.? SELECT ALL THAT APPLY. 1) Roman Catholics 2) Homeless 3) Mentally ill 4) Japanese 5) People with physical disabilities 6) Older adults

Answer 48

Feedback 1: correct. Roman Catholics are not a vulnerable population in the United States. Feedback 2: correct. Vulnerable populations are groups who are more likely to develop health problems and experience poorer outcomes because of limited access to care, high-risk behaviors, and/or multiple and cumulative stressors. The homeless are a vulnerable population in the United States. Feedback 3: correct. The mentally ill are a vulnerable population in the United States. Feedback 4: correct. The Japanese are not a vulnerable population in the United States. Feedback 5: correct. People with physical disabilities are a vulnerable population in the United States. Feedback 6: correct. Older adults are a vulnerable population in the United States.

Question 49

You work with patients with a variety of conditions, many of whom you must assist with activities of daily living (ADLs) during their stay in the hospital. You should be prepared to provide hygiene assistance to patients with which of the following conditions? SELECT ALL THAT APPLY. 1) Severe pain resulting from third-degree burns 2) Stage I hypertension 3) Diabetes mellitus 4) Rheumatoid arthritis and limited mobility 5) Macular degeneration 6) Schizophrenia

Answer 49

Feedback 1: Pain severely limits the person's ability and motivation to perform ADLs. Feedback 2: Hypertension, which typically has no symptoms, would not likely prevent a client from performing his or her own ADLs. Feedback 3: Diabetes mellitus would not likely prevent a client from performing his or her own ADLs. Feedback 4: Limited mobility (e.g., from joint and muscle problems, injury, weakness, fatigue, surgery, prescribed bedrest, or pain) makes it difficult to perform hygiene activities. Rheumatoid arthritis is a chronic, progressive disease involving inflammation of the joints and leading to disability. Feedback 5: Sensory deficits, such as poor vision caused by macular degeneration, diminish a person's ability to perform hygiene measures safely and independently. Safety is a priority for patients with sensory deficits. Feedback 6: Patients experiencing altered reality states, such as psychoses, delusions, or hallucinations, may dress inappropriately for the weather or the situation and have poor hygiene practices. Patients with schizophrenia often experience hallucinations. Chapter number and title: Chapter 25: Facilitating Hygiene

Question 50

Below are the steps for making an occupied bed. Put them in the correct order. Place clean linens on the side nearest you. Roll the soiled linens under the patient. Move to the other side of the bed. Tuck the clean linens under the soiled linens. Assess the patient's ability to move and need for assistive equipment. Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail. Position the patient laterally near the far siderail. Pull the soiled and clean linens through, and complete the linen change.

Answer 50

To make an occupied bed, complete the following steps: 1. Assess the patient's ability to move and need for assistive equipment and patient-handling devices. 2. Position the patient laterally near the far siderail. 3. Roll soiled linens under him. 4. Place clean linens on the side nearest you. 5. Tuck the clean linens under the soiled linens. 6. Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail. 7. Move to the other side of the bed. 8. Pull the soiled and clean linens through, and complete the linen change.

Question 51

You are assessing a client's self-care abilities and begin by obtaining a health history. Which of the following is the correct rationale for this action? 1) To determine overall grooming and cleanliness 2) To identify underlying illness, injury, or disease that might contribute to a self-care deficit 3) To assess for tactile disturbances 4) To assess pain

Answer 51

2) To identify underlying illness, injury, or disease that might contribute to a self-care deficit The purpose of obtaining a health history as part of assessing a client's self-care abilities is to identify underlying illness, injury, or disease that might contribute to a self-care deficit or affect tolerance of hygiene procedures.

Question 52

As you work as a medical missionary in a developing nation, you discover how much your beliefs, values, and practices have been influenced by the cultural norms of the North American healthcare system. Which of the following are characteristics of this system? SELECT ALL THAT APPLY. 1) A focus on living in harmony with nature 2) A desire to conquer disease 3) Emphasis on handwashing 4) Annual physical examinations 5) Prayer as a means of healing 6) Use of amulets to promote health

Answer 52

Feedback 1: Living in harmony with nature is a Native American belief. Feedback 2: The desire to conquer disease is a value of the North American healthcare system. Feedback 3: Handwashing is a habit encouraged by the North American healthcare system. Feedback 4: Annual physical examinations and diagnostic tests are practices encouraged by the North American healthcare system. Feedback 5: Prayer is a healing practice associated with various religions and cultures but not with the North American healthcare system. Feedback 6: The use of medicinal amulets is a practice of Asians and Pacific Islanders.

Question 53

According to the U.S. Census Bureau, which of the following are races? SELECT ALL THAT APPLY. 1) White 2) African American 3) German 4) Chinese 5) Hispanic 6) Vietnamese

Answer 53

Feedback 1: White is a race. Feedback 2: Black, African American, or Negro is a race. Feedback 3: German is not a race but a nationality. Feedback 4: Chinese is a race. Feedback 5: People of Hispanic, Latino, or Spanish origin may be of any race, because the U.S. Census Bureau includes Hispanic/Latino/Spanish as a sociocultural rather than a race category. Feedback 6: Vietnamese is a race.

Question 54

The mother of a newborn says she is concerned about how much her child is sleeping. She says, "It seems like he is asleep all the time. Is that normal?" Which of the following is the average range of required sleep in hours for a newborn? 1) 11 to 13 2) 12 to 14 3) 14 to 16 4) 16 to 20

Answer 54

4) 16 to 20 Newborns (birth to 4 weeks) require 16 to 20 hours of sleep per day, on average.

Question 55

As you are providing oral hygiene for a client, you notice some white patches and ulcers on the oral mucosa. Which of the following actions should you take? 1) Explain to the client that he may have oral cancer. 2) Encourage the client to see a dentist immediately. 3) Recommend that the client increase his intake of vitamin B12. 4) Urge the client to brush his teeth and floss regularly.

Answer 55

The client should be referred to a dentist, who can proceed with the proper diagnostic tests to confirm or rule out oral cancer.

Question 56

A client is complaining to you about how she never sees her husband because he usually goes to bed around 9 at night and gets up at 5 in the morning before heading off to work. She, however, wakes up at 8 in the morning and goes to bed at midnight. Which of the following is the most likely explanation for the differences between the client and her husband? 1) Gender 2) Stress levels 3) Circadian rhythms 4) Sleep cycles

Answer 56

A circadian rhythm is a biorhythm based on the day–night pattern in a 24-hour cycle. Circadian rhythm affects our overall level of functioning; for example, most people have a higher energy level in the daytime and less energy at night. However, some people are more alert and active in the morning, and others function at a higher level in the afternoon or evening.

Question 57

You are interviewing a client who is struggling with insomnia. Which of the following lifestyle factors might be contributing to this client's lack of sleep? SELECT ALL THAT APPLY. 1) Exercising 3 hours before bedtime 2) A high-fat dinner at 9 pm 3) Heavy alcohol consumption 4) Smoking 5) Opioid medications 6) Satiation following a predominantly carbohydrate meal

Answer 57

Feedback 1: If it occurs at least 2 hours before bedtime, exercise promotes sleep. Feedback 2: A meal high in saturated fat near bedtime may interfere with sleep. Feedback 3: Consumption of alcohol, especially if heavy, may hasten the onset of sleep; however, it disrupts rapid eye movement (REM) and slow wave sleep and may cause spontaneous awakenings with difficulty returning to sleep. Feedback 4: Central nervous system stimulants, such as nicotine and caffeine, interfere with sleep. Smokers tend to have more difficulty falling asleep and are more easily roused than nonsmokers. Feedback 5: Opioids, such as morphine, suppress REM sleep and cause frequent awakening. Feedback 6: Carbohydrates seem to promote relaxation through their effects on brain serotonin levels. In general, satiation induces sleep.

Question 58

As you are bathing an older client who has urinary incontinence, you notice that the skin of her perineal area is soft, fragile, and white. Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne

Answer 58

Maceration is softening of the skin from prolonged moisture (e.g., urinary incontinence). It makes the epidermis more susceptible to injury.

Question 59

You have just arranged a follow-up appointment for a patient who is from Nicaragua, Central America, for next Thursday at 8 a.m. Given what you know about the time orientation of this culture, which of the following should you expect? 1) The client will likely show up 15 minutes early to the appointment. 2) The client will likely show up right on time. 3) The client will likely call ahead of time to reschedule the appointment. 4) The client will likely show up as soon as he has finished a conversation he started with his neighbor.

Answer 59

4) The client will likely show up as soon as he has finished a conversation he started with his neighbor. Being from a present-oriented culture, this client is more likely to live in the moment and will show up as soon as he has completed whatever he's doing at the time of the appointment.

Question 60

A female nurse is providing directions within the hospital to a male client who is from Saudi Arabia. Given the client's cultural background, which of the following behaviors should the nurse expect from this client? 1) To stand at least 18 inches away from her 2) To avoid direct eye contact with her 3) To use a lot of body language when communicating 4) To engage her in a casual conversation

Answer 60

Arabs and others from the Middle East tend to keep steady eye contact, but not between men and women.

Question 61

A client you are caring for takes a variety of herbs connected with her culture's folk medicine. After investigating the herbs, you find that one of them will likely cause adverse reactions when used in conjunction with the blood pressure medicine the client has just been prescribed. Through an interpreter, you explain this to the client and recommend that she discontinue use of the one herb but continue the others. Which transcultural care strategy are you employing here? 1) Repatterning/restructuring 2) Negotiation 3) Collaboration 4) Respect

Answer 61

2) Negotiation The client's perspective may differ from yours about the effects of a particular practice. Negotiation acknowledges that gap. You must negotiate when folk or traditional practices might be harmful to the client.

Question 62

You moisten 10 washcloths with sterile water and a pH-balanced, no-rinse soap, warm them up, and then cleanse each part of a client's body using a fresh cloth. Which type of bath are you giving the client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath

Answer 62

A bag bath is a modification of the towel bath, in which you use 8 to 10 washcloths instead of a towel and bath blanket. They are moistened with water (preferably sterile, filtered, or distilled) or a pH-balanced, no-rinse soap. They are then warmed and each part of the patient's body is cleansed with a fresh cloth.

Question 63

Which of the following are effects of a client performing personal hygiene and activities of daily living (ADLs) for herself? SELECT ALL THAT APPLY. 1) Promotes comfort 2) Promotes dependence 3) Improves self-image 4) Decreases infection and disease 5) Decreases activity 6) Increases risk of anxiety

Answer 63

Feedback 1: ADLs, such as taking a bath or shower, washing hair, or brushing and flossing teeth, promote comfort. Feedback 2: Encouraging as much self-care as possible promotes independence, not dependence. Feedback 3: ADLs improve self-image. Feedback 4: ADLs decrease infection and disease. Feedback 5: Encouraging as much self-care as possible promotes, not decreases, activity. Feedback 6: Encouraging as much self-care as possible promotes self-esteem, not anxiety. Chapter number and title: Chapter 25: Facilitating Hygiene

Question 64

A client complains of waking from unrefreshing sleep in the morning and dozing off during the day. His wife claims that he snores loudly at night and occasionally stops breathing temporarily. Which of the following sleep disorders should you most suspect in this client? 1) Insomnia 2) Narcolepsy 3) Obstructive sleep apnea 4) Bruxism

Answer 64

Obstructive sleep apnea is a periodic interruption in breathing during sleep caused by airway occlusion (usually by the tongue or palate). Sleeping partners often report that the person snores, snorts, grunts, or thrashes about during sleep. Many people with sleep apnea complain of unrefreshed sleep, fatigue and morning headache, and easily falling asleep during sedentary activity.

Question 65

You are performing a physical assessment on a client who is of a different culture from your own. Which of the following aspects of the assessment is most likely to be influenced by the client's culture? 1) Pain 2) Reflexes 3) Auscultation of lungs 4) Oral temperature

Answer 65

1) Pain Culture influences the patient's responses to pain. Because pain and comfort are subjective responses, you need to quantify your client's pain as objectively as possible by using a pain measurement scale.

Question 66

As part of an initial assessment of a client who is being admitted to the hospital for cardiac bypass surgery, you are inquiring about the client's sleeping habits. Which of the following topics should you ask about? SELECT ALL THAT APPLY. 1) Usual sleeping pattern 2) Sleeping environment 3) Self-reported sleep history 4) Bedtime routines/rituals 5) Sleep changes or problems 6) Sleep diary

Answer 66

Feedback 1: A brief assessment for all patients should include questions about usual sleeping pattern. Feedback 2: A brief assessment for all patients should include questions about the sleeping environment. Feedback 3: When you suspect a sleep problem, you will perform a more in-depth assessment, such as a detailed sleep history or sleep diary. In this case, there is not enough evidence to indicate a sleep problem. Feedback 4: A brief assessment for all patients should include questions about bedtime routines or rituals. Feedback 5: A brief assessment for all patients should include questions about sleep changes or problems. Feedback 6: When you suspect a sleep problem, you will perform a more in-depth assessment, such as a detailed sleep history or sleep diary. In this case, there is not enough evidence to indicate a sleep problem.

Question 67

You are delegating the bathing of a client to a nursing assistive personnel (NAP). About which of the following should you give instructions to the NAP? SELECT ALL THAT APPLY. 1) Patient's family history of multiple sclerosis 2) Mobility limitations 3) Use of a walker 4) Medication allergy 5) Presence of intravenous (IV) tubing 6) Skin condition

Answer 67

Feedback 1: The patient's family history of multiple sclerosis would not be pertinent to communicate to the NAP before assistance with a bath, shower, or toileting. Feedback 2: Before assigning a NAP to assist with a bath, shower, or toileting, give instructions about the patient's limitations and restrictions and the amount of assistance necessary. Feedback 3: Relate to the NAP the use of any assistive devices (e.g., cane, walker, or gait belt). Feedback 4: The patient's medication allergies would not be pertinent to communicate to the NAP before assistance with a bath, shower, or toileting. Feedback 5: Describe any obstacles present, such as drainage tubes, catheters, IV tubing, or bandages, and explain how to maintain them during bathing or toileting. Feedback 6: Mention any observations to make during the procedure and why the observations are important (e.g., skin condition; presence of lesions; areas of special concern over bony prominences and under abdominal folds and breasts; presence, appearance, and amount of urine or stool; or the need to collect a specimen).

Question 68

You are providing hygiene care for an older client who requires assistance with activities of daily living. When you ask her how often she typically bathes, she replies, "A couple of times per week." How should you respond to the client? 1) Agree to bathe her twice per week. 2) Insist on bathing her daily for health reasons. 3) Agree to bathe her twice a week, but insist on using a substantial amount of deodorant soap. 4) Encourage her to bathe only once a week and to use a skin moisturizer instead.

Answer 68

Older adults may find it necessary to bathe only every 2 or 3 days, use less soap, and increase the use of skin moisturizers.

Question 69

You are checking on a client at night and find that he is sleeping. His eyes are moving rapidly and twitching underneath his eyelids. What other characteristics are associated with this rapid eye movement (REM) stage of sleep? SELECT ALL THAT APPLY. 1) It is the deepest stage of sleep. 2) If awakened, the person is likely to be confused. 3) It is essential for mental and emotional restoration. 4) The pulse may be rapid and irregular. 5) Dreaming occurs. 6) Metabolism, temperature, and blood pressure decrease.

Answer 69

Feedback 1: REM sleep is highly active with spontaneous awakenings and is less restful than non-REM (NREM) sleep. Stage IV NREM sleep is the deepest sleep. Feedback 2: If awakened during REM sleep, the person will react normally. If roused during stage IV of NREM sleep, the person may be confused. Feedback 3: REM sleep is essential for mental and emotional restoration. Feedback 4: During REM sleep, the pulse may be rapid and irregular. Feedback 5: Dreaming occurs primarily during REM sleep. Feedback 6: Metabolism, temperature, pulse, and blood pressure increase, not decrease, during REM sleep.

Question 70

You are caring for an older adult who complains of frequent sleep disturbances. Which of the following are likely causes of sleep disturbances or decreased sleep in this age group? SELECT ALL THAT APPLY. 1) Nocturia 2) Medication side effects 3) Increase in melatonin levels 4) Depression 5) Hormonal fluctuations 6) Staying up late to watch television

Answer 70

Feedback 1: Nocturia, or waking at night to urinate, is a common cause of sleep disturbance among older adults. Feedback 2: Medication side effects are a common cause of sleep disturbance among older adults. Feedback 3: A decline, not increase, in melatonin levels is associated with decreased sleep among older adults. Feedback 4: Depression is a common cause of sleep disturbance among older adults. Feedback 5: Hormonal fluctuations are a common cause of sleep disturbance among middle-aged menopausal women, not among older adults. Feedback 6: Staying up late to watch television is a common cause of sleep disturbance among teenagers, not among older adults.

Question 71

You are caring for an older client who is the primary caregiver for her mother, a 90-year-old woman with Alzheimer's disease who lives with the client. The client appears exhausted. When you ask how much sleep she typically gets each night, she says, "Three or four hours, if I'm lucky. I constantly have to get up in the night to look after mom." When you ask how long this has been going on, the client thinks a minute and then replies, "Oh, about 6 months or so." Which of the following would be the most appropriate nursing diagnosis for this client? 1) Insomnia related to intensive demands of caregiving 2) Sleep Deprivation related to providing constant care to elderly mother with Alzheimer's disease 3) Disturbed Sleep Pattern (premature awakening) related to anxiety secondary to caregiving 4) Anxiety related to lack of sleep secondary to caregiving

Answer 71

Use Sleep Deprivation as the nursing diagnosis when the patient's amount, consistency, or quality of sleep is decreased over prolonged periods of time. Defining characteristics of Sleep Deprivation are more severe than those for Disturbed Sleep Pattern.

Question 72

You are caring for a client who can participate in dressing herself but requires assistance because of a severe tremor in her hands resulting from Parkinson's disease. She does not use any assistive devices. Which of the following would be the most accurate diagnosis for this client? 1) Dressing Self-Care Deficit (2) related to hand tremors secondary to Parkinson's disease 2) Self-Care Deficit (dressing) related to Parkinson's disease secondary to hand tremors 3) Parkinson's disease related to hand tremors as evidenced by Dressing Self-care Deficit (3) 4) Dressing Self-Care Deficit (1) related to Parkinson's disease as evidenced by hand tremors

Answer 72

The primary problem at this time is the self-care deficit related to dressing, with the etiology being hand tremors secondary to Parkinson's disease. Because the client does not use any devices and can participate in the self-care but requires assistance, the functional level of 2 should be included in the diagnosis.

Question 73

You have completed your assessment of a client who is of a different culture from your own. You have developed several nursing diagnoses based on your assessment. Which of the following nursing diagnoses should you be most cautious about using with this client, given the culture gap between the two of you? 1) Noncompliance related to care of a healing wound 2) Excess fluid volume related to ineffective cardiac muscle function 3) Activity intolerance related to joint pain 4) Constipation related to gastrointestinal obstructive lesions

Answer 73

You should use the Noncompliance diagnosis cautiously and only after completing a cultural assessment. Geissler (1991) found that additional defining characteristics are needed before Noncompliance can be appropriately applied to clients not of the dominant U.S. culture.

Question 74

After explaining the concept of circadian rhythms to a client, the client asks you, "How does your body know when to make you sleepy and when to wake you up? What controls it?" Which of the following should you mention? 1) A cluster of cells in the hypothalamus of the brainstem responds to changing levels of light. 2) A region in your cerebral cortex responds to changing external temperatures. 3) An area in your inner ear responds to changes in air pressure. 4) Receptors in your diencephalon respond to changing levels of oxygen saturation in the blood.

Answer 74

1) A cluster of cells in the hypothalamus of the brainstem responds to changing levels of light. A person's circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brainstem that respond to changing levels of light.

Question 75

Which of the following are characteristics of culture? SELECT ALL THAT APPLY. 1) Provides identity and a sense of belonging 2) Consists of common beliefs and practices 3) Is innate and genetically transmitted 4) Is static 5) Is complex 6) Demonstrates the uniformity that exists among groups and individuals

Answer 75

Feedback 1: Cultural beliefs provide identity and a sense of belonging for its members as long as they do not conflict with the dominant culture and continue to satisfy its members. Feedback 2: Most members of a culture share the same beliefs, traditions, customs, and practices as long as they continue to be adaptive and satisfy the members' needs. Some members of the group may deviate from cultural norms, but for a norm to be considered cultural, many members must follow it. Feedback 3: Culture is learned and taught. Cultural values, beliefs, and traditions are passed down from generation to generation. Learning occurs through life experiences shared with other members of the culture, either formally (e.g., in schools) or informally (e.g., in families). Feedback 4: Culture is dynamic and adaptive. Cultural customs, beliefs, and practices are not static. They change over time and at different rates. Feedback 5: Culture is complex. Cultural assumptions and habits are unconscious and thus may be difficult for members of the culture to explain to others or to identify as different from another culture. Feedback 6: Culture is diverse. Culture demonstrates the variety that exists among groups and among members of a particular group.

Question 76

You are surprised to learn that two of your clients, both with the same illness, have opposite problems with sleep, both caused by the illness. One struggles with insomnia whereas the other sleeps too much each day. Which of the following illnesses is most likely to produce these opposite results? 1) Allergies 2) Depression 3) Hyperthyroidism 4) Parkinson's disease

Answer 76

Depression may be associated either with too much sleep or with insomnia.

Question 77

You care for several clients who have conditions whose signs and symptoms tend to present at night when the client is sleeping. Which of the following are examples of such sleep-provoked disorders? SELECT ALL THAT APPLY. 1) Narcolepsy 2) Restless leg syndrome (RLS) 3) Asthma 4) Chronic obstructive pulmonary disease (COPD) 5) Diabetes 6) Gastric ulcers

Answer 77

3,4,5,6 Feedback 1: Narcolepsy is a chronic disorder caused by the brain's inability to regulate sleep–wake cycles normally. At various times, the person with narcolepsy experiences a sudden, uncontrollable urge to sleep lasting from seconds to minutes, even though the person sleeps well at night. Although it is a sleep disorder, it is not a "sleep-provoked" disorder. Feedback 2: RLS is a disorder of the central nervous system characterized by an uncontrollable movement of the legs while resting or before sleep onset. Although it is a sleep disorder, it is not a "sleep-provoked" disorder. Feedback 3: People with asthma may experience bronchospasm during rapid eye movement (REM) sleep. In adults, asthma attacks frequently occur during the night as the esophageal sphincter relaxes and reflux results. In children, they occur mostly during the final two-thirds of the night, when there is less stage IV sleep. Feedback 4: Persons with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control is normally depressed. This can result in pulmonary spasm and transient pulmonary hypertension. Feedback 5: When diabetes is uncontrolled, it may profoundly affect the blood sugar level during sleep, when the person is not alert enough to deal with it. Therefore, patients with uncontrolled diabetes may need to have blood glucose levels monitored during sleep. Feedback 6: During REM sleep, people with duodenal ulcers secrete up to 20 times more gastric acid than do people who do not have duodenal ulcers. Peptic ulcers also contribute to increased acid, often producing nocturnal epigastric pain and sleep loss.

Question 78

Which of the following is an example of a cultural stereotype, as opposed to a cultural archetype? 1) Native Americans have black hair. 2) Northern Europeans have light-colored skin 3) Asians are good at math. 4) Jewish people have prominent noses.

Answer 78

3) Asians are good at math A cultural stereotype is a widely held but oversimplified and unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects. Stereotypes are not always negative. Someone may think, for example, that people of a particular heritage are "naturally intelligent" or "naturally athletic."

Question 79

You are providing eye care to a patient who is in a coma. Which of the following should you do? 1) Lubricate the eyes with saline every 2 to 4 hours. 2) Use a protective eye shield to keep the eyes open. 3) Instill eye ointment in the upper lids. 4) Occasionally stimulate the client's blink reflex to help lubricate the eye.

Answer 79

1) Lubricate the eyes with saline every 2 to 4 hours. Comatose or critically ill patients need more frequent eye care (every 2 to 4 hours). Keep their eyes lubricated with saline or artificial tears to protect them from corneal abrasions and drying.

Question 80

You are caring for a client who has struggled with insomnia for the past year. Which of the following changes in this client's health resulting from lack of sleep should you expect to see? SELECT ALL THAT APPLY. 1) Increased incidence of upper respiratory infections 2) Weight loss 3) Type 2 diabetes 4) Decreased ability to learn 5) Decreased stress 6) Increased sensitivity to pain

Answer 80

1,3,4,6, Feedback 1: Lack of sleep increases the susceptibility to illness by compromising the immune system. Feedback 2: Sleep restriction is linked to increased appetite through changes in the appetite control hormones, leptin and ghrelin. Additionally, not enough sleep leads to reduced energy expenditure, which can lead to obesity (not weight loss) and type 2 diabetes. Feedback 3: Without sleep, the body is less able to tolerate glucose and yet responds with insulin resistance, eventually leading to type 2 diabetes. Feedback 4: Sleep gives the individual a chance to mentally repeat and rehearse facts and situations before they are encountered in wakeful life and thus may improve learning and adaptation. Conversely, a lack of sleep decreases the ability to learn. Feedback 5: Sleep appears to reduce stress and anxiety, improving our ability to cope and concentrate on activities of daily living. Conversely, a lack of sleep increases, not decreases, stress. Feedback 6: More sleep reduces the body's sensitivity to pain. A lack of sleep, conversely, would lead to an increased sensitivity to pain.

Question 81

A client arrives at your clinic complaining of insomnia and asking for a prescription. You explain that the physician will first examine the client and then determine the appropriate course of treatment. Which medication would you most likely expect the physician to order for this client? 1) Nonbenzodiazepine 2) Benzodiazepine 3) Barbiturate 4) Tricyclic antidepressant

Answer 81

The benzodiazepines class of sedative/hypnotics is the first-line treatment for insomnia, and includes both long-acting and short-acting drugs.

Question 82

As you are bathing a client, you notice a yellow discoloration of the sclerae of the eyes. Which of the following conditions should you suspect in this client? 1) Lack of peripheral perfusion 2) Vasodilation and inflammation 3) Decreased oxygenation of the blood 4) Impaired liver function

Answer 82

Impaired liver function is indicated by jaundice, or a yellow discoloration of the skin and of the sclerae of the eyes.

Question 83

Which of the following is an example of a culture universal? 1) Grieving the loss of a loved one 2) Cremation of the dead 3) Holding a wake for the deceased 4) Wearing black clothing while in mourning

Answer 83

1) Grieving the loss of a loved one

Question 84

You are monitoring an electroencephalogram (EEG) of a child who is in deep sleep. You see that the child's brain activity as represented on the EEG is dominated by low-frequency, high-amplitude brain waves. Which type of brain waves are these? 1) Alpha 2) K-complexes 3) Theta 4) Delta

Answer 84

Delta waves are low-frequency, high-amplitude, regular waves common in deep sleep

Question 85

You are teaching a client with diabetes how to care for her feet. Which of the following guidelines should you give her? SELECT ALL THAT APPLY. 1) Inspect the feet daily using a mirror to view all surfaces. 2) Soak the feet daily. 3) File down callused areas. 4) Check between the toes for cracks or redness. 5) Wear open-toed shoes when possible to expose the feet to air. 6) Apply over-the-counter corn medicines to the feet.

Answer 85

Feedback 1: Inspect the feet daily, using a mirror to view all surfaces. Feedback 2: Avoid soaking the feet (if you are diabetic, or if there is decreased circulation to the feet). Feedback 3: Do not cut or file callused areas. Feedback 4: Check between the toes for cracks or redness. Feedback 5: Avoid open-toed shoes, sandals, high heels, and thongs. They do not protect the feet. Feedback 6: Do not put tape or over-the-counter corn medicines or pads or other medications (e.g., hydrogen peroxide) on the feet.

Question 86

The non–rapid eye movement (NREM)/rapid eye movement (REM) sleep cycle occurs how many times, on average, throughout the night? 1) Two to four 2) Three to five 3) Four to six 4) Five to seven

Answer 86

The NREM/REM sleep cycle repeats four to six times throughout the night, depending on the total amount of time spent sleeping.

Question 87

You are working with a client who is taking anti-anxiety medication and who visits her primary care provider regularly to manage her hypertension. She also receives massage therapy weekly to manage stress and to help her relax. In this case, massage therapy is an example of which type of medicine? 1) Folk 2) Complementary 3) Alternative 4) Biomedical

Answer 87

Complementary medicine is the use of rigorously tested therapies that are outside of mainstream medical or nursing care to complement those of conventional medicine, such as the use of massage therapy to complement medications and medical assessments.

Question 88

You are working with a client who is originally from Mexico but is now an American citizen. Which of the following terms most accurately describes this client's ethnicity? 1) Mexican American 2) Hispanic 3) Latino 4) Spanish

Answer 88

1) Mexican American If you know a client's country of origin, it is more accurate to use it when referring to the client's ethnicity (e.g., Mexican American, Colombian American) than to use any of the terms Hispanic, Latino, or Spanish.

Question 89

A Japanese patient and his young son arrive at the community clinic where you work. The patient tells you something in Japanese and pats his chest. The son speaks English. How should you respond to this patient? 1) Tell the boy to ask the father whether he can wait for an interpreter to arrive. 2) Ask the son to serve as an interpreter. 3) Assume that the patient is having a heart attack and call an ambulance to take him to the nearest emergency room. 4) Tell the boy to explain to the patient that he should come back the following day, when a physician who speaks Japanese will be on duty.

Answer 89

1) Tell the boy to ask the father whether he can wait for an interpreter to arrive. The best way to provide culturally competent care to clients who do not speak English is to use a professional medical interpreter. An interpreter is specially trained to provide the meaning behind the words. An interpreter can serve as a cultural broker by conveying the client's responses to questions and by providing general information about the client's culture. Unless the situation is a true emergency, it would be best to wait for the interpreter to arrive.