FADAVIS.com quiz questions Flashcards
What is an integrated plan of care?
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.
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
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.
- 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
3) Proprioceptors
- 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.
1) Client will not experience a fall while in the hospital.
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
1) Severe asthma
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
1) Risk for Falls r/t visual impairment
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.
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.
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.
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).
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
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.
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
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.
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
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.
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.
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.
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
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.
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
3) Continuity of care for patient
The purpose of giving an oral report is to maintain continuity of care.
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
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.
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
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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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
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.
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
2) Administering activated charcoal
For most poisonings, the most effective intervention is professional administration of activated charcoal orally or via gastric tube.
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
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.
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.
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.”
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.
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?”
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
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.
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.
The steps for performing otic irrigation on an adult client are as follows:
- Warm the irrigating solution to body temperature.
- Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear.
- Straighten the ear canal by pulling up and back on the pinna.
- Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation.
- 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.
- Continue irrigating until the canal is clean.
- Perform an otoscopic examination.
- Place a cotton ball loosely in the outer ear.
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
Poisoning motor vehicle accidents firearms falls drowning fires
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
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.
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
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.
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
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.
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.
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.
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
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.
