NSG 100 Exam 4: Nutrition, Elimination, and Comfort Flashcards
An elderly, tense patient is having trouble relaxing enough to sleep. Which measures should be implemented by the nurse to help promote sleep? (Select all that apply.)
a. Give the patient a back rub.
b. Take the patient for a brisk walk right before bedtime.
c. Provide a warm, quiet environment.
d. Encourage the patient to eat a large meal in the evening.
e. Give the patient a diet cola.
f. Play soft music 30 minutes before bedtime.
a. Give the patient a back rub.
c. Provide a warm, quiet environment.
f. Play soft music 30 minutes before bedtime.
Rationale: Giving a back rub, providing a warm and quiet environment, and playing soft music enhance relaxation, which will lead to easier transition into sleep. Brisk exercise, caffeine drinks, and large meals all are contraindicated in the evening because they induce changes that will interfere with sleep.
A nurse who was hired to work in a sleep lab understands that the most common type of sleep apnea is caused by which factor?
a. Airway collapse
b. Lack of exercise
c. Dietary factors
d. Medication use
a. Airway collapse
Rationale: Airway collapse of the soft structures of the upper airway is the most common cause of sleep apnea.
Lack of exercise and certain dietary factors may adversely affect sleep patterns, especially the initiation of sleep.
Medications in the proper dose seldom cause sleep apnea unless improperly combined with other medications or taken with alcohol.
A patient has been referred for polysomnography to confirm a diagnosis of narcolepsy. What behavior would the nurse expect the patient to be exhibiting?
a. Excessive use of sleeping medications
b. A lack of dreaming during sleep
c. Consistent use of relaxation techniques
d. Unexpected daytime sleeping episodes
d. Unexpected daytime sleeping episodes
Rationale: Narcolepsy is characterized by uncontrolled and unexpected episodes of falling asleep during the day.
Because of sleeping too much, sleep medications and relaxation techniques are not needed.
The patient goes almost directly to rapid eye movement (REM) sleep upon falling asleep, so vivid dreaming would be expected.
A mother brings her toddler for a well-child checkup and mentions that she is having a lot of trouble getting the child to go to bed. Which intervention can the nurse teach the mother to help her toddler establish good sleep habits?
a. Establish and maintain a consistent bedtime routine.
b. Put the child to bed immediately after the evening meal.
c. Allow the child to stay up as long as desired to increase sleepiness.
d. Allow the child to sleep with the parents until the child is older.
a. Establish and maintain a consistent bedtime routine.
Rationale: Toddlers and preschoolers benefit from a consistent routine to help their sleep patterns.
Putting the child to bed too early (right after a meal) will not help sleep; any bedtime snacks should be light snacks containing carbohydrates.
The child will become too tired if allowed to stay up as long as desired, with consequent sleep disruption the next day.
The American Academy of Pediatrics does not recommend that children sleep with their parents.
An elderly patient complains of difficulty sleeping after the death of his spouse of 56 years. What would be an appropriate nursing assessment for this patient?
a. Assess the patient for possible use of sedatives.
b. Obtain a health history regarding sleep hygiene.
c. Assess the patient’s weight over the past year.
d. Request a sleep study to rule out sleep apnea.
b. Obtain a health history regarding sleep hygiene.
Rationale: Obtaining a health history of the patient’s sleep hygiene will help determine interventions that might promote relaxation and sleep.
Sedatives are prescribed for only some patients with chronic, ongoing sleep disturbances that interfere with daily life after nonpharmacologic methods have been tried. Although assessing the patient’s weight is an important part of a physical exam, weight is not related to the type of sleep problem described.
No symptoms of sleep apnea have been reported, so the nurse would not request a sleep study.
The nurse is completing a sleep assessment for a newly admitted patient. Which data reported by the patient would cause the nurse to suspect obstructive sleep apnea? (Select all that apply.)
a. Morning headaches
b. Sudden weight loss
c. Loud snoring during sleep
d. Daytime sleepiness
e. Deep sleep during the night
f. Increased blood pressure problems
a. Morning headaches
c. Loud snoring during sleep
d. Daytime sleepiness
f. Increased blood pressure problems
Rationale: Signs of obstructive sleep apnea include headaches from hypoxemia on first awakening, loud snoring related to airway collapse, daytime sleepiness from nonrestorative sleep at night, and increased hypertension. Sudden weight loss is not associated with obstructive sleep apnea, although it can be related to other medical disorders such as cancer. Deep sleep is not obtained with obstructive sleep apnea, because the affected person experiences many awakenings during the night.
A patient complains of not being able to sleep while in the hospital. What action would be a priority for the nurse to implement?
a. Administer a sleeping medication with the evening meal.
b. Restrict visitors for the patient in the evening.
c. Decrease noise around the patient during the night.
d. Offer a hot drink of regular tea at bedtime.
c. Decrease noise around the patient during the night.
Rationale: Noise is a primary cause of disturbed sleep in the hospital. Administering sleeping medications with the evening meal is too early to help the patient sleep throughout the night.
Restricting visitors may be helpful if the patient requests it, but visitors often provide emotional support and reassurance to the patient, which helps with relaxation. Regular tea contains caffeine, which is not helpful in sleep promotion.
A patient reports that the prescribed sleeping medication is no longer effective. What information would be appropriate for the nurse to recommend to the patient? (Select all that apply.)
a. Take the medication with an alcoholic drink.
b. Use relaxation techniques before sleep.
c. Do not study in the bedroom before bedtime.
d. Adjust sleep temperature for comfort.
e. Sleep in a different room of the home.
b. Use relaxation techniques before sleep.
c. Do not study in the bedroom before bedtime.
d. Adjust sleep temperature for comfort.
Rationale: Tolerance frequently develops to sleeping medications, especially with long-term use, and additional sleep hygiene practices such as mindful relaxation, only sleeping in the bedroom, and creating a comfortable environment can be effective adjunctive measures. Alcohol plus a sleeping medication is a dangerous combination. Sleeping in an alternate room removes the patient from the familiar setting and is more likely to disrupt sleep.
A nurse is working a night shift after several months of working day shift. What action does the nurse take to protect patient safety?
a. Take a meal break at midnight.
b. Plan critical tasks for early in the shift.
c. Ask another nurse to administer all medications.
d. Turn up lights on the unit to maintain alertness.
b. Plan critical tasks for early in the shift.
Rationale: The 4 A.M. window is when most people become the sleepiest during the night, so it is important that noncritical tasks be planned for this time and that extra care be taken with patient care tasks.
A meal break at midnight may be too early to prevent hunger for the entire shift and is not directly related to patient safety. It is not necessary to have another nurse administer all medications if the nurse is aware of the high-risk time for care tasks. Increasing the amount of light is likely to impair the sleep of all patients on the unit.
At a routine clinic visit, an athlete training for a major sports event reports difficulty sleeping that is affecting the training schedule. What would be the best recommendation by the nurse for this patient?
a. Increase the use of electrolyte-enriched drinks to increase stamina.
b. Obtain a short-term prescription for sleeping medications.
c. Plan to arise later in the morning to accommodate sleep changes.
d. Avoid vigorous exercise for at least 2 hours before bedtime.
d. Avoid vigorous exercise for at least 2 hours before bedtime.
Rationale: Vigorous exercise in the hours before bedtime will cause stimulation that prevents sleep.
Adjusting the training schedule to account for this effect is the preferred first step for improving the athlete’s sleep, rather than starting medications that may affect alertness during the day.
A regular sleep schedule is preferred to maintain sleep promotion, including getting up at the same time each day no matter when bedtime occurred.
Which lifestyle changes should the nurse recommend to a patient with recent onset of insomnia related to a job change?
a. Obtain a prescription for sleep medication.
b. Increase evening alcohol intake to induce relaxation.
c. Arise each day at the same time.
d. Increase evening exercise to promote sleepiness.
c. Arise each day at the same time.
Rationale: Arising at the same time each day is an important measure to help regulate circadian sleep patterns.
Non-pharmacologic measures should be tried before medication due to the potential side effects of medications.
While alcohol may initially relax some people, it interferes with later sleep patterns. Exercise should not be done for at least 2 hours before bedtime as it inhibits relaxation.
A patient reports using a combination of prescription sleeping medication and alcohol every night for the past 8 months after the loss of her job. She tells the nurse that she now wants to stop taking the sleeping medications. What teaching would be appropriate for the nurse to provide?
a. The same sleep routine should be followed until the patient finds another job.
b. An additional prescription medication will be needed.
c. The medication should not be stopped suddenly.
d. Diet changes will be needed before stopping the medication.
c. The medication should not be stopped suddenly.
Rationale: Sleeping medications should not be stopped abruptly to minimize withdrawal symptoms.
Sleep medications are best used short-term, so continuing for an unknown length of time is not advisable.
It is not recommended to add additional medications as medication effects will be much increased.
Diet changes are not necessary when stopping sleep medications, although decreasing alcohol, caffeine, and tobacco use are recommended when starting sleep medications.
A patient returns to the clinic requesting an increase in prescribed sleeping medication. What teaching should the nurse provide regarding the long-term use of sleeping medications?
a. “Long-term use of sleeping medications is an appropriate treatment.”
b. “Adding diet changes will increase the effects of the medication.”
c. “More medication will cause hallucinations.”
d. “Long-term use of sleeping medications can increase sleep disorders.”
d. “Long-term use of sleeping medications can increase sleep disorders.”
Rationale: The long-term use of sleeping medications actually is detrimental to sleep promotion and is not recommended, even with any diet changes. Sleep deprivation can ultimately cause hallucinations.
A nurse is completing discharge planning for a new mother and newborn infant. Which statement by the mother indicates an understanding of infant care?
a. “Sleep patterns of a newborn are irregular.”
b. “I will put a small pillow and bumpers in the crib.”
c. “My baby should sleep through the night within a week.”
d. “Babies sleep best when placed on their stomachs.”
a. “Sleep patterns of a newborn are irregular.”
Rationale: It is correct that the sleep of the newborn is irregular.
A caregiver who plans to place an infant on his or her stomach to sleep needs further teaching that the recommended position to decrease the risk for SIDS is supine, or on his or her back.
Pillows and other soft objects should not be used in the crib to decrease the risk of suffocation, and babies do not sleep through the night until approximately 4 months of age.
A patient who is trying to lose weight requests information from the nurse to improve sleep patterns. What recommendation would be appropriate for this patient?
a. Do not drink diet colas for at least 4 hours prior to bed.
b. Increasing evening exercise will increase sleepiness.
c. High protein bedtime snacks are appropriate.
d. Using diet pills will improve sleep patterns.
a. Do not drink diet colas for at least 4 hours prior to bed.
Rationale: Caffeine is commonly in cola drinks and interferes with sleep when ingested within 4 hours of bedtime.
Exercise should not be done in the hours prior to sleep.
A bedtime snack containing carbohydrates is preferred as protein helps the brain stay alert. Diet pills may contain stimulants that prevent good sleep.
A patient has been diagnosed with obstructive sleep apnea. What teaching regarding a common intervention for this disorder is the nurse likely to initiate?
a. The proper use of devices to support the patency of the airway
b. The correct administration of sleeping medications
c. The use of a supine position for sleeping
d. The use of caffeine to maintain alertness
a. The proper use of devices to support the patency of the airway
Rationale: Obstructive sleep apnea is caused by airway collapse, so the use of an oral airway, continuous positive airway pressure, or other devices that keep the airway open are commonly prescribed.
Sleep medications may further relax airway structures, increasing the problem.
Sleeping in a supine position increases the risk of the tongue falling to the back of the throat and blocking the airway.
Caffeine does maintain alertness and does not promote sleep.
The nurse knows that the desired outcome for a sleep-deprived patient has been met when the patient makes which comment?
a. “I have less of a headache every morning.”
b. “I have enough energy to do my housework every day.”
c. “I only get up three times during the night to go to the bathroom.”
d. “I only smoke one pack of cigarettes per day now.”
b. “I have enough energy to do my housework every day.”
Rationale: A common result of sleep deprivation is fatigue during the day that prevents a person from completing required tasks, so the outcome of being able to do his or her work is a desirable outcome.
With adequate sleep and oxygenation, there should be no morning headaches.
Getting up several times during the night to void adds to sleep deprivation.
Tobacco products act as stimulants and their use will continue to disrupt sleep.
A patient admitted to the hospital complains of sharp, tingling sensations in his lower extremities that prevent him from sleeping. The nurse suspects the patient may have which sleep disorder?
a. Obstructive sleep apnea
b. Narcolepsy
c. Restless leg syndrome
d. Insomnia
c. Restless leg syndrome
Rationale: Restless leg syndrome is characterized by sharp, often painful sensations in the calves and legs that are relieved with walking or movement. Obstructive sleep apnea signs include fatigue, snoring, and periods of apnea while sleeping. Narcolepsy presents with sudden episodes of falling asleep even while doing tasks during the day. Insomnia presents as difficulty falling or staying asleep.
A parent is a primary caregiver for a child with multiple disabilities requiring constant care. The parent reports sleeping in 45-minute blocks during the night, having trouble concentrating, and being increasingly irritable. The nurse recognizes that this parent is consistently missing what stage of sleep?
a. Nonrapid eye movement (NREM) stage 2
b. Rapid eye movement (REM) stage
c. Sleep latency stage
d. Sleep arousal stage
b. Rapid eye movement (REM) stage
Rationale: The rapid eye movement stage of sleep is needed to complete the restorative function of sleep and is needed to prevent the cognitive effects of sleep deprivation. Nonrapid eye movement stages begin the sleep cycles and reset with stage one if sleep is interrupted. Sleep latency occurs prior to sleep occurring, and sleep arousal is prior to awakening; neither is a specific stage of sleep.
A summer camp nurse is prescreening a school-age child who has a diagnosis of sleep enuresis. What intervention does the nurse expect the child to request while at camp?
a. Separate sleeping area to use a bed alarm
b. Separate sleeping area close to the bathroom
c. Separate sleeping area for a later bedtime
d. Separate sleep area with access to bedtime snacks
a. Separate sleeping area to use a bed alarm
Rationale: Use of a bed alarm is an effective intervention for enuresis; having an area where the alarm can be used in privacy will decrease any stigma associated for the child. Children do not wake up in response to the urge to void, so being close to the bathroom will not decrease the enuresis. Enuresis is not affected by a later bedtime or bedtime snacks, although caffeinated foods or drinks may increase the incidence of enuresis.
Which sleep disorders are dyssomnias? Select all that apply.
A. Narcolepsy
B. Hypersomnia
C. Somnambulism
D. Sleep deprivation
E. Nocturnal enuresis
A. Narcolepsy
B. Hypersomnia
D. Sleep deprivation
Rationale: Dyssomnia is primary sleep disorder characterized by a decreased amount or quality of sleep or by irregular sleep timings. Dyssomnias include narcolepsy, hypersomnia, and sleep deprivation. Parasomnias include abnormal sleep behaviors and include somnambulism and nocturnal enuresis.
A patient reports difficulty falling asleep. Further assessment shows that the patient consumes alcohol. What are the effects of alcohol on sleep? Select all that apply.
A. Alcohol promotes sleep.
B. Alcohol prevents the patient from falling asleep.
C. Alcohol causes the patient to remain awake.
D. Alcohol awakens the patient early and causes difficulty returning to sleep.
E. Alcohol limits rapid eye movement (REM) sleep.
A. Alcohol promotes sleep.
D. Alcohol awakens the patient early and causes difficulty returning to sleep.
E. Alcohol limits rapid eye movement (REM) sleep.
Rationale: Small amounts of alcohol may help some people fall asleep, but alcohol increases wakefulness in the last half of the night. Ingesting large quantities of alcohol creates difficulty falling asleep and limits REM sleep, and this may cause a restless sleep and the sensation of a “hangover” on arising.
The nurse is learning about various stages of nonrapid eye movement (NREM) sleep. One particular stage of NREM lasts for 15 to 30 minutes. It is the deepest stage of sleep, and it is very difficult to arouse the sleeper from this stage. The vital signs are lower than normal waking hours. Which stage of NREM sleep is the nurse referring to? Record your answer using a whole number. __________
4
Rationale: The stage 4 of NREM sleep is the deepest stage and lasts for 15 to 30 minutes. The stage is characterized by lowering of vital signs. It may be difficult to arouse the sleeper from this stage.
Which neurotransmitter levels are elevated during non-rapid eye movement (NREM) sleep? Select all that apply.
A. Serotonin
B. Melatonin
C. Acetylcholine
D. Norepinephrine
E. Gamma aminobutyric acid (GABA)
A. Serotonin
E. Gamma-aminobutyric acid (GABA)
Rationale: Sleep consists of two phases, rapid eye movement sleep (REM) and non-rapid eye movement (NREM) sleep. Serotonin and GABA are neurotransmitters that induce NREM sleep; therefore, one can find high levels of these neurotransmitters during NREM sleep. Melatonin is a hormone, not a neurotransmitter, and its levels generally increase at night. The levels of neurotransmitters such as acetylcholine and norepinephrine increase during REM sleep.
A patient who recently immigrated to the United States tells the nurse, “I am unable to sleep and concentrate on my work.” What might be the reason for this condition?
- Sleep apnea
- Hypersomnia
- Sleep terror disorder
- Circadian rhythm sleep disorder
- Circadian rhythm sleep disorder
Rationale: When a person travels from one time zone to another, he or she may face difficulty in adjusting to the time changes. This causes difficulty in sleeping, memory problems, depression, weight gain, and impaired concentration levels.
This type of sleep disorder is termed a circadian rhythm sleep disorder. Sleep apnea is shallow or absent breathing during sleep. Hypersomnia is a sleep-wake disorder in which a person sleeps excessively during the daytime, even after a normal 8 to 12 hours of sleep at night. A patient who has sleep terror disorder wakes suddenly in a terrified state from deep sleep.
Which substances may produce insomnia if consumed in the evening? Select all that apply.
A. Alcohol
B. Nicotine
C. Caffeine
D. Light meal
E. Protein-rich diet
A. Alcohol
B. Nicotine
C. Caffeine
Rationale: Consumption of alcohol, nicotine, and caffeine in the evening produces insomnia. Nicotine and caffeine act as stimulants and produce sleeplessness. Alcohol interferes with the quality of sleep. A light meal and protein-rich diet do not cause insomnia.
Which complications does the nurse expect to find in a patient who is on beta blockers? Select all that apply.
A. Insomnia
B. Irritability
C. Drowsiness
D. Nightmares
E. Restlessness
A. Insomnia
D. Nightmares
Rationale: Beta-blockers inhibit the effects of the adrenaline hormone and also inhibit the nighttime secretion of melatonin, a hormone involved in regulating both sleep and the body’s circadian clock.
Reduced secretions of melatonin, which induces sleep, result in insomnia and nightmares.
Irritability occurs due to sleep deprivation. Drowsiness and restlessness occur due to over usage of medications such as barbiturates, amphetamines, and antidepressants.
A patient reports difficulty falling asleep. The nurse asks questions to assess the symptoms of insomnia and analyzes the different stages of the patient’s sleep cycle. What are the characteristics of stage 2 of nonrapid eye movement (NREM) sleep? Select all that apply.
A. Sleepwalking may occur.
B. Body functions become slow.
C. Arousal remains relatively easy.
D. Muscles relaxation increases.
E. Vital signs are significantly lower than during waking hours.
B. Body functions become slow.
C. Arousal remains relatively easy.
D. Muscles relaxation increases.
Rationale: In stage 2 of nonrapid eye movement (NREM) sleep, the body functions become slow. The sleeper can be easily aroused in this stage. The muscles continue to relax. A person may sleepwalk during stage 4 of NREM sleep. Also during stage 4, the vital signs are lower than they are during waking hours.
Which stage of the sleep cycle is associated with snoring?
- NREM 1
- NREM 2
- NREM 3
- NREM 4
- NREM 2
Rationale: Snoring is a condition characterized by noisy breathing during the second stage of non-rapid eye movement (NREM) sleep.
As the physiological functions become slower in this stage, sleep becomes deeper, and snoring occurs. Snoring does not occur in the other stages of sleep.
Drowsiness occurs in NREM 1 stage. Vital signs decrease and muscles relax in NREM 3 stage. Somnambulism and nocturnal enuresis may occur in NREM 4 stage.
A nurse has a sleep disorder due to working on rotating shifts. Which physiologic symptoms are observed in the nurse? Select all that apply.
A. Fatigue
B. Increased reflexes
C. Difficulty concentrating
D. Decreased neuromuscular coordination
E. Increased visual alertness
A. Fatigue
C. Difficulty concentrating
D. Decreased neuromuscular coordination
Rationale: Sleep deprivation can occur due to rotating shifts, as the human biologic clock becomes maladjusted. It can lead to symptoms of fatigue, headache, nausea, increased sensitivity to pain, decreased neuromuscular coordination, irritability, and difficulty concentrating.
What complications does the nurse expect to find in a patient who has circadian rhythm sleep disorders? Select all that apply.
A. Tremors
B. Cataplexy
C. Depression
D. Hypertension
E. Sexual dysfunction
C. Depression
D. Hypertension
E. Sexual dysfunction
Rationale: Improper sleep due to circadian rhythm sleep disorders decreases dopamine levels, which causes depression. Increases in stress hormones due to insufficient sleep cause hypertension.
The metabolic rate decreases due to improper sleep; this causes an imbalance in sex hormones and results in sexual dysfunction. Tremors occur due to the withdrawal of barbiturate-sedative hypnotics.
Cataplexy is the loss of muscle tone that occurs in a patient who has narcolepsy.
What are the withdrawal symptoms of barbiturate sedative-hypnotics? Select all that apply.
A. Tremors
B. Restlessness
C. Skin irritation
D. Increased pulse rate
E. Claustrophobia sensations
A. Tremors
B. Restlessness
D. Increased pulse rate
Rationale: Withdrawal symptoms occur upon the abrupt cessation of drugs after prolonged use. Barbiturate sedative-hypnotics that are used to reduce anxiety can cause physical and psychological dependence and result in withdrawal symptoms.
Barbiturates bind to the gamma-aminobutyric acid (GABA) receptor site and show indirect agonist action on these receptors. This may be responsible for the occurrence of tremors upon withdrawal.
Barbiturate sedative-hypnotics may also cause central nervous system stimulation and hyperadrenergic activity upon withdrawal. Thus, it may cause restlessness and increase the patient’s pulse rate. Skin irritation and claustrophobia sensations are side effects of continuous positive airway pressure, which is used to treat obstructive sleep apnea.
When assessing the patient for pain, which factors should the nurse consider? (Select all that apply.)
a. Previous medical history
b. Physical appearance
c. Age, gender, and culture
d. Lifestyle and loss of appetite
e. Hair color and style
a. Previous medical history
b. Physical appearance
c. Age, gender, and culture
d. Lifestyle and loss of appetite
Rationale: Medical history, physical appearance, age, gender, culture, lifestyle, and loss of appetite should be considered when conducting a pain assessment. Hair color and style are not necessary components of a pain assessment.
Which statement best describes the dosage of pain medication that a nurse should administer given pharmacologic treatment considerations?
a. The smallest dose possible to avoid opioid addiction
b. The smallest dose possible to decrease adverse effects
c. A dose that best manages pain with the fewest side effects
d. A large dose initially decreases the initial level of pain.
c. A dose that best manages pain with the fewest side effects
Rationale: Based on the patient’s report of pain, the nurse administers the dose of medication that is effective in relieving pain without causing adverse side effects. Administering too small of a dose does not relieve pain. Administering a large dose may result in unwanted side effects. Addiction to narcotics is rare.
Which method is the most accurate way to determine the pain level of a patient who is alert and oriented?
a. Evaluate whether the patient is crying or grimacing.
b. Assess the patient’s heart rate and blood pressure.
c. Consider the seriousness of the patient’s condition.
d. Use a pain assessment tool and ask the patient to rate the pain level.
d. Use a pain assessment tool and ask the patient to rate the pain level.
Rationale: Because pain is defined as what a patient says it is, a patient’s report based on the pain scale is currently the most accurate way to determine the pain level of a cognitively alert patient.
Crying or grimacing may be considered on a noncognitive scale for a nonverbal patient. Vital signs and the patient’s condition contribute to a pain assessment, but they may not be the most accurate determinants.
A patient who has a serious back injury received intravenous medication for pain approximately 1 hour earlier. The patient practices relaxation techniques but still is reporting pain at a level of 9 of 10. What intervention should the nurse implement next?
a. Report the lack of pain relief to the primary care provider.
b. Tell the patient to give the medication more time.
c. Reposition the patient, and try diversion activities.
d. Document in the nurse’s notes that the patient has a low pain tolerance.
a. Report the lack of pain relief to the primary care provider.
Rationale: If the patient with a serious injury is not obtaining pain relief from pharmacologic and nonpharmacologic interventions, the primary care provider should be notified. Waiting longer and using more nonpharmacologic interventions are not likely to relieve pain in this situation.
Which symptom does the nurse recognize as a physiologic response to acute pain?
a. Increased blood pressure
b. Decreased pulse
c. Increased temperature
d. Restlessness
a. Increased blood pressure
Rationale: Acute pain can increase blood pressure and pulse rate but may not affect temperature. Restlessness is a psychological response, not physiologic.
When administering medications to elderly patients, what information does the nurse need to understand?
a. Start with a low dosage, and increase the dosage as needed for pain relief.
b. Start with a high dosage, and decrease the dosage as pain is relieved.
c. Start with a mid-range dosage, and increase or decrease the dosage as needed for pain.
d. Start with a low dosage, and decrease the dosage as indicated for pain
a. Start with a low dosage, and increase the dosage as needed for pain relief.
Rationale: Due to decreased metabolism and clearance of medications, start with a lower dose and increase as indicated for pain relief. A high dose may result in drug toxicity. Too low of a dose will not relieve pain.
The nurse administered intravenous morphine at 0830. At what time will the nurse ask the patient if pain relief was obtained?
a. 1000
b. 1030
c. 0900
d. 0930
c. 0900
Rationale: After administering intravenous medication, check the patient in 15 to 30 minutes for relief from pain. Intravenous medication is injected directly into the bloodstream and bypasses the gastric system metabolism.
The patient who had a below-the-knee amputation 3 days ago complains of pain from the amputated extremity. Which statement by the nurse best explains what the patient is experiencing?
a. “The phantom pain will subside when the brain realizes the lower extremity is no longer there.”
b. “The radiating pain will continue for months because the lower extremity is no longer there.”
c. “You are suffering from referred pain, which you will always have, but it will lessen with time.”
d. “You are experiencing psychogenic pain because loss of an extremity is an emotional loss.”
a. “The phantom pain will subside when the brain realizes the lower extremity is no longer there.”
Rationale: Feeling an extremity after amputation is phantom pain. This type of pain decreases over time as the brain adjusts to the missing extremity. Radiating, referred, and psychogenic types of pain are not the source of this patient’s discomfort.
The endocrine system releases excessive hormones during episodes of acute pain. The nurse should monitor patients experiencing acute pain for which potential problem?
a. Hyperglycemia
b. Migraine headache
c. Hyperkalemia
d. Diarrhea
a. Hyperglycemia
Rationale: The release of hormones causes the blood glucose level to increase, causing hyperglycemia. Hypokalemia may result from the metabolic effects of the genitourinary injury. Constipation results from decreased intestinal motility. Migraine headaches are not a result of hormone release during acute pain.
A patient with a fractured femur thinks about vacationing on the beach to relieve pain. What nonpharmacologic pain relief technique should the nurse document the patient is using?
a. Distraction
b. Imagery
c. Relaxation
d. Biofeedback
b. Imagery
Rationale: Imagery is the use of visual concentration to change the perception of pain. Distraction is the use of music or television to occupy the mind to decrease concentration on pain. Relaxation is muscle relaxation to decrease anxiety created by pain. Biofeedback enables voluntary control over the body to decrease pain
The patient who had surgery to remove part of the intestines is complaining of pain. What type of pain is the patient experiencing?
a. Somatic pain
b. Visceral pain
c. Referred pain
d. Radiating pain
b. Visceral pain
Rationale: Visceral pain is pain originating from a body organ. Somatic pain is bone, muscle, etc. originating pain. Referred pain is pain in a different area from where pain originated. Radiating pain extends into another area of the body.
A patient complains of shoulder pain during a gallbladder attack. How does the nurse document this pain?
a. Referred pain
b. Phantom pain
c. Chronic pain
d. Psychogenic pain
a. Referred pain
Rationale: Referred pain is pain in another area of the body from where the pain originated. Phantom pain is pain from an amputated extremity that is no longer present. Chronic pain is pain that lasts more than 6 months. Psychogenic pain is pain without a physical cause.
The patient has been experiencing chronic pain from fibromyalgia for the past six months. What change will the nurse note in the patient’s vital signs?
a. Increase in blood pressure and pulse
b. Decrease in blood pressure and pulse
c. Increase in temperature and respirations
d. Decrease in temperature and respirations
b. Decrease in blood pressure and pulse
Rationale: Chronic pain stimulates the parasympathetic system resulting in a decrease in blood pressure and pulse. Acute pain causes an increase in blood pressure and pulse. Temperature and respirations are not affected.
What are the signs of opioid withdrawal? Select all that apply.
A. Itching
B. Anxiety
C. Vomiting
D. Drowsiness
E. Hypertension
B. Anxiety
C. Vomiting
E. Hypertension
Rationale: Opioid drugs are categorized as narcotic analgesics that have addictive properties. Sudden withdrawal might be lethal, so opioid doses should be gradually tapered off.
They may cause withdrawal symptoms that are very uncomfortable to the patient, including anxiety, restlessness, fear, and nervousness.
The patient may also experience vomiting and hypertension. Itching is a histaminic reaction, not a withdrawal symptom, observed in patients who take opioid analgesics. Drowsiness is also a side effect of opioid analgesics, but it is not evident upon withdrawal.
The nurse is caring for a patient who reports mild headache and fever. Which medication does the nurse expect the primary health care provider to recommend for this patient?
- Docusate (Colace)
- Naloxone (Narcan)
- Atenolol (Tenormin)
- Acetaminophen (Tylenol)
- Acetaminophen (Tylenol)
Rationale: Acetaminophen (Tylenol) is an analgesic drug that helps in relieving pain at various locations of the body; therefore, it can also help in relieving a headache. Acetaminophen (Tylenol) also acts as an antipyretic and is used to reduce fever. Docusate (Colace) is useful in treating constipation. Naloxone (Narcan) is useful in treating respiratory depression caused by an overdose of opioid analgesics. Atenolol (Tenormin) is a drug that is useful in treating hypertension.
Which conditions does the nurse identify as causes of visceral pain? Select all that apply.
A. Arthritis
B. Appendicitis
C. Fibromyalgia
D. Pancreatitis
E. Pyelonephritis
B. Appendicitis
D. Pancreatitis
E. Pyelonephritis
Rationale: Viscera generally refers to the soft internal organs of the body such as the appendix, pancreas, and kidneys. Appendicitis refers to inflammation of the appendix, which causes pain in the abdomen. Pancreatitis refers to inflammation of the pancreas, which causes severe upper abdominal pain radiating to the back. Pyelonephritis refers to kidney infection, which causes pain in the back and on the side of the abdomen. Arthritis refers to joint pain, which is not considered visceral pain because it is not related to the soft internal organs. Fibromyalgia refers to chronic muscle pain at tender points and limbs, which are somatic organs.
The nurse is assessing touch, pain, and temperature sensation of a patient who is diagnosed with diabetic neuropathy. Arrange the parts of the central nervous system through which pain sensation is carried in ascending order.
- Cerebrum
- Thalamus
- Medulla, pons, midbrain
- Spinal cord
- Cerebrum
- Thalamus
- Medulla, pons, midbrain
- Spinal cord
Rationale: Pain sensation is transmitted from afferent fibers to the spinal cord. From the spinal cord, the pain sensation is carried to medulla, pons, and midbrain. From here it continues through the spinothalamic tract to the thalamus and then to cerebrum.
A patient with bronchial carcinoma reports constipation for the past 2 months. The patient is on meperidine (Demerol) and ibuprofen (Advil) for pain relief for the past 6 months. The patient is also taking metformin and captopril (Capoten) for the past 10 years. What could be the most probable reason for constipation in the patient?
- Side effect of opioid
- Side effect of captopril
- Interaction of metformin and captopril
- Metastasis of cancer to other organs
- Side effect of opioid
Rationale: Constipation is a common side effect of opioids that are used for pain relief. Captopril is an ACE-inhibitor drug that is used to treat hypertension. Cough is the common side effect of captopril. Metformin is an oral hypoglycemic drug. Interaction between metformin and captopril does not cause constipation. It is unlikely that metastasis of cancer caused constipation.
Which type of pain does a patient experience after undergoing minor surgery?
- Chronic pain
- Referred pain
- Nociceptive pain
- Psychogenic pain
- Nociceptive pain
Rationale: Nociceptors are present on the sensory neurons on the skin and internally in the tissues and organs. These receptors carry sensory stimuli, including pain stimuli, from the site of injury to the cerebral cortex.
Surgery involves cutting the patient’s skin and the tissues that contain nociceptors, so a patient who has undergone surgery experiences nociceptive pain.
Chronic pain refers to pain that lasts for a long period of time, approximately 3 to 6 months. This type of pain is observed in conditions such as arthritis, fibromyalgia, and neuropathy. The patient would not likely experience chronic pain after minor surgery.
Referred pain is observed in a patient who has pain at one particular site, but the perception of pain is felt at another site. It is observed in cases of appendicitis and myocardial infarction. Pain after surgery would be perceived at the site of the operation.
Psychogenic pain occurs due to persistent mental and emotional factors, and there is no physical cause for the pain.
Which drug does the nurse expect the primary health care provider to prescribe a patient who is recovering from a myocardial infarction?
- Aspirin
- Naloxone (Narcan)
- Oxycodone (Dazidox)
- Acetaminophen (Tylenol)
- Aspirin
Rationale: A myocardial infarction occurs due to the aggregation of platelets in the arteries. Aspirin is a nonsteroidal antiinflammatory drug that acts against blood clots formed due to platelet aggregation. Naloxone (Narcan) is useful in treating respiratory depression caused by overdose of opioid analgesics. Oxycodone (Dazidox) is an agonist analgesic that is useful in treating severe pain. Acetaminophen (Tylenol) is useful in treating mild headaches and fever.
The nurse is assessing a patient with acute pain. Which statements are true about acute pain? Select all that apply.
A. Patients with acute pain are more likely to suffer from depression and fatigue.
B. Acute pain has an identifiable cause.
C. Acute pain lasts less than 6 months.
D. Anxiety increases the severity of acute pain.
E. Patients with acute pain seek numerous healthcare providers.
B. Acute pain has an identifiable cause.
C. Acute pain lasts less than 6 months.
D. Anxiety increases the severity of acute pain.
Rationale: Acute pain has an identifiable cause. The duration of acute pain is less than 6 months, and that of chronic pain is longer than 6 months. In acute pain, the presence of anxiety increases the severity of the pain experienced, reduces the individual’s tolerance to pain, and decreases the ability to cope with pain. Individuals with chronic pain are more likely to suffer from depression and fatigue and are more likely to attempt suicide. A patient with chronic pain may seek numerous healthcare providers if the pain has an unknown cause.
The nurse is caring for a young patient with cancer who is intubated and conscious. How does the nurse best assess pain in this patient?
- By using the Wong-Baker Facial Grimace Scale
- By monitoring the patient’s blood pressure and pulse rate
3, By asking the patient to point out his or her pain score on a pain assessment tool - By asking the patient to verbally report the pain score on a pain assessment tool
3, By asking the patient to point out his or her pain score on a pain assessment tool
Rationale: The patient is conscious and is intubated. In this case, the nurse explains the pain assessment tool to the patient and then asks the patient to point out the pain score on the tool. The patient is young and not cognitively impaired; therefore, the nurse need not assess pain with the Wong-Baker Facial Grimace Scale. The patient is conscious; therefore, the nurse need not monitor the patient’s blood pressure and pulse rate to assess pain as would be done for an intubated patient who is sedated. The patient is intubated and therefore would not be able to verbally communicate a score on a pain assessment tool.
The nurse is caring for a patient who underwent surgery and has a diagnosis of acute pain. Which clinical manifestations does the nurse expect to find in this patient? Select all that apply.
A. Tachycardia
B. Bradycardia
C. Hypertension
D. Hypotension
E. Constipation
A. Tachycardia
C. Hypertension
E. Constipation
Rationale: Surgery may cause acute pain (pain that lasts for less than 6 months). Acute pain causes an increase in sympathetic nerve activity; thus, it causes an increase in heart rate (tachycardia) and an increase in blood pressure (hypertension). Pain normally affects the gastrointestinal tract by decreasing gastric motility and thereby causing constipation. Chronic pain causes a decreased heartbeat (bradycardia) and a decrease in blood pressure (hypotension).
A patient is under preoperative care for an elective surgery. After understanding the explanation given by the nurse about spinal anesthesia, the patient expresses fear of becoming paralyzed due to spinal anesthesia. How should the nurse respond in this situation?
- Send the patient home as it is not a surgical emergency.
- Ask the healthcare provider to postpone the surgery without patient’s permission.
- Arrange an appointment with a surgical counselor as soon as possible.
- Reassure the patient and explain that numbness, tingling, and coldness are common symptoms.
- Reassure the patient and explain that numbness, tingling, and coldness are common symptoms.
Rationale: 4. Reassure the patient and explain that numbness, tingling, and coldness are common symptoms. The nurse should be aware that many patients fear paralysis when they learn about spinal or epidural anesthesia. This is because epidural and spinal injections come close to the spinal cord. Therefore, the nurse should reassure the patient and explain that numbness, tingling, and coldness are common following spinal anesthesia. Sending the patient home or asking the healthcare provider to postpone the surgery may not help to relieve the patient’s fears. An appointment with the surgical counselor may be arranged if the nurse is unable to reassure the patient.
The nurse explains patient-controlled analgesia to a patient. If the patient has understood this information, what would be the patient’s most appropriate statement?
- The device reduces the risk of an overdose of medication.
- The caregivers can operate the device if the patient is unable to do so.
- The patient will be lying down in a prone lying position during the procedure.
- The patient will decide about the loading dose of the analgesic drug.
- The device reduces the risk of an overdose of medication.
Rationale: A nurse should teach about the use of patient-controlled analgesia to a patient before any procedure. It is important to tell the patient that PCA reduces any risk of overdose. It should be emphasized to the patient that the patient-controlled analgesia device (PCA device) should not be operated by caregivers. The caregivers are not able to perceive the patient’s pain and thus cannot decide the amount of drug required. The patient would be placed in a comfortable position in which the IV line is accessible. This prone position is not likely to be a comfortable position for the patient. The patient does not decide the loading dose of the drug; the loading dose is already prescribed.
An elderly patient complains of severe pain in both lower extremities. The patient becomes tearful when describing the pain and states that it is intolerable. How should the nurse develop a healing relationship with the patient? Select all that apply.
A. By inquiring how the pain is affecting the patient’s daily routine.
B. By telling the patient about various pain-relieving interventions.
C. By encouraging the patient to be strong and deal with the pain positively.
D. By asking the family to help the patient cope with pain and anxiety.
E. By administering pain medications and encouraging the patient to exercise.
A. By inquiring how the pain is affecting the patient’s daily routine.
B. By telling the patient about various pain-relieving interventions.
D. By asking the family to help the patient cope with pain and anxiety.
Rationale: To establish a healing relationship and a helping role, the nurse should not just look at the patient’s leg pain as a medical problem. The nurse should also try to understand how it affects patient’s daily life and spirituality, and work to improve the patient’s overall well-being. By informing the patient about various methods to alleviate pain, the nurse mobilizes hope in the patient. The nurse should also help the patient use social resources, such as friends and family, who can help the patient deal with her health condition. Asking the patient to be strong and deal with the pain may decrease spirituality and increase stress and anxiety. The nurse should focus on more than just medications and exercise to develop a healing relationship.
A patient is admitted to the hospital for multiple injuries and is put on an intravenous analgesia. After a couple of hours, the patient is still in severe pain. The nurse finds that the skin around the intravenous catheter is red and swollen. The nurse finds no other changes in the patient’s condition. What should be the immediate response of the nurse?
- Notify the primary healthcare provider.
- Change the pain medication.
- Change the intravenous access line.
- Increase the dose of pain medication.
- Change the intravenous access line.
Rationale: The nurse should continuously monitor the intravenous access line to check its patency. Pain medication or analgesics are effective only if the intravenous (IV) access is patent. The swelling around the intravenous catheter indicates that the IV line is blocked. Therefore, the nurse should first change the intravenous access line. If there is no improvement in the patient’s condition after changing the IV line, then the nurse should notify the primary healthcare provider. The primary healthcare provider would change the analgesic or increase the dose of the analgesic drug if necessary.
A nurse is assessing a hospitalized patient with acute pain. Which questions should the nurse ask the patient for an appropriate assessment? Select all that apply.
A. “How bad is your pain now?”
B. “What makes your pain worse?”
C. “Describe your pain.”
D. “What is the worst pain you have had in the past 24 hours?”
E. “Show me where you hurt. Does it stay there or does it spread?”
B. “What makes your pain worse?”
C. “Describe your pain.”
E. “Show me where you hurt. Does it stay there or does it spread?”
Rationale: When assessing a patient with acute pain, the questions should be specific. The questions should aim to determine intensity, location, and quality of pain. Ask for provocative factors like what makes the pain worse. Ask about the region of the pain and the radiation of pain. Asking how bad the pain is may not yield specific details. Instead the patient should be asked to rate the pain on a scale of 0 to 10. Other details can be asked once the patient is comfortable.
Which patients would be appropriate for application of acupuncture therapy? Select all that apply.
A. A patient with back pain
B. A patient with a skin infection
C. A patient with myofascial pain
D. A patient with a bleeding disorder
E. A patient with a migraine headache
A. A patient with back pain
C. A patient with myofascial pain
E. A patient with a migraine headache
Rationale: Acupuncture therapy regulates the vital energy, which flows like a river through the body in channels that form a system of pathways. Back pain, myofascial pain, and migraine headaches are chronic conditions believed to be caused by a disruption to flow of energy in the body. Acupuncture helps to realign the flow of energy and relieve symptoms of back pain, myofascial pain, and migraine headaches. Acupuncture therapy is contraindicated for clients who have a skin infection or bleeding disorder.
The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which
information is of concern?
a. The patient’s son uses a marked pillbox to set up the patient’s medications
weekly.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
c. The patient is cared for by a daughter during the day and stays with a son at night.
d. The patient tells the nurse that a close friend recently died.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI)
of 31. How should the nurse instruct this patient?
a. “Your weight is within normal limits. Continue maintaining with current lifestyle choices.”
b. “You are a little overweight. Cut down on calories and increase your activity, and
you should be fine.”
c. “You are morbidly obese, and we would like to schedule you an appointment to
speak with a bariatric specialist about surgery.”
d. “You are considered obese and will need to consult with your doctor about a plan
that includes exercises, not diet, to decrease weight.”
d. “You are considered obese and will need to consult with your doctor about a plan
that includes exercises, not diet, to decrease weight.”
The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this
patient?
a. Regular diet
b. Low sodium diet
c. Pureed diet
d. Low sugar diet
b. Low sodium diet
During a nutritional assessment, the nurse calculates that a female patient’s BMI is 27. The nurse would advise the patient to
follow which of these recommendations?
a. This measurement indicates that the patient is overweight and should follow a
plan of diet and exercise to lose weight.
b. This measurement indicates that the patient is underweight and will need to take
measures to gain weight.
c. This measurement indicates that the patient is morbidly obese and may be a
candidate for bariatric surgery.
d. This measurement indicates that the patient is of normal weight and should
continue with current lifestyle.
a. This measurement indicates that the patient is overweight and should follow a
plan of diet and exercise to lose weight.
During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick
screening tool to assess dietary intake?
a. Food diary
b. Calorie count
c. Comprehensive diet history
d. 24-hour recall
d. 24-hour recall
During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
a. Vitamin C
b. Vitamin B
c. Essential fatty acid
d. Protein
c. Essential fatty acid
During a physical examination, the nurse notes that the patient’s skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency?
a. Hair loss and hair that is easily removed from the scalp
b. Inflammation of the tongue and fissured tongue
c. Inflammation of peripheral nerves and numbness and tingling in extremities
d. Fissures and inflammation of the mouth
a. Hair loss and hair that is easily removed from the scalp
An African American is at an increased risk for which of the following? (Select all that apply.)
a. Vitamin D deficiency
b. Type 1 diabetes
c. Celiac disease
d. Type 2 diabetes
e. Hypertension
f. Metabolic syndrome
a. Vitamin D deficiency
d. Type 2 diabetes
e. Hypertension
f. Metabolic syndrome
Rationale: Type 1 diabetes and celiac disease are more common in Northern European heritage.
The nurse is providing education to a patient about the difference between simple and complex carbohydrates. Which statement by
the patient indicates a need for further education?
a. “Simple carbohydrates give me quick energy.”
b. “Complex carbohydrates come from fruit.”
c. “Complex carbohydrates take longer to break down.”
d. “Simple carbohydrates come from milk products.”
b. “Complex carbohydrates come from fruit.”
The nurse teaches the family member to provide the patient with how much dietary fiber per day?
a. 25 to 35 g
b. 20 to 35 g
c. 25 to 40 g
d. 20 to 40 g
b. 20 to 35 g
The nurse is providing education to an older adult around a healthy diet to support the challenges related to aging. Which statement
indicates a need for further education?
a. “I should choose foods that are nutrient dense.”
b. “High-fiber foods minimize the risk of constipation.”
c. “I should eat more calories to avoid malnutrition.”
d. “I can add spices to enhance the taste of food.”
c. “I should eat more calories to avoid malnutrition.”
When caring for an adolescent patient with anorexia nervosa, the nurse knows what would be the best treatment option for this patient?
a. Hospitalization with skill nursing care
b. Compulsory tube feedings
c. Individually determined by a collaborative team
d. Outpatient treatment
c. Individually determined by a collaborative team
A new UAP is measuring a patient’s height. Which step of the procedure indicates a need for the registered nurse to provide further
education on this skill?
a. The UAP instructs the patient to remove shoes.
b. The UAP measures from the top of the patient’s head to the bottom of the
patient’s foot arch.
c. The UAP positions the head against the headboard or measuring device.
d. The UAP makes sure the patient is standing erect.
b. The UAP measures from the top of the patient’s head to the bottom of the
patient’s foot arch.
The nurse is performing an oral examination on a patient and notices a beefy-red tongue. The nurse identifies this as a characteristic
finding for what condition?
a. Anorexia nervosa
b. Malnutrition
c. Bulimia
d. Pernicious anemia
d. Pernicious anemia
The nurse has delegated the feeding of a patient who has recently had a stroke to the UAP. Which procedure that the UAP performs
would demonstrate a need for further education?
a. Uses thickened liquids.
b. Puts the bed at 25 degrees.
c. Encourages slow eating.
d. Has the patient alternate between food and sips of fluid.
b. Puts the bed at 25 degrees.
The nurse recognizes which outcome statement to be appropriate for the nursing diagnosis Impaired swallowing?
a. Patient will consume 50% of each meal.
b. Patient will gain 2 lb a week.
c. Patient will not show any signs of aspiration during meals.
d. Patient will demonstrate using an assistive device to feed self.
c. Patient will not show any signs of aspiration during meals.
The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation?
a. “I can give the patient orange juice.”
b. “I can give the patient yogurt.”
c. “I can give the patient oatmeal.”
d. “I can give the patient milk.”
c. “I can give the patient oatmeal.”
The nurse is educating a patient about a renal diet. Which statement by the patient indicates a need for further education?
a. “I need to eat a low-sodium diet.”
b. “I can have limited amounts of meat.”
c. “I can drink unlimited cola if it is diet.”
d. “I should avoid or limit bananas.”
c. “I can drink unlimited cola if it is diet.”
The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable
method to determine enteral tube placement?
a. Auscultation of air bolus
b. Measurement of pH of the aspirate
c. Radiographic image
d. Aspirate contents to visually inspect appearance
c. Radiographic image
The nurse is attempting to open an occluded PEG tube. Which intervention by the nurse requires re-education?
a. Flushes the tube with a small amount of air.
b. Flushes the tube using a 50- to 60-mL syringe and warm water.
c. Reinserts the stylet to break up the clot.
d. Flushes the tube with a special enzyme solution.
c. Reinserts the stylet to break up the clot.
When the nurse is caring for a patient who is receiving total parenteral nutrition (TPN), the nurse will change the tubing at which
interval?
a. Every 72 hours
b. Every 48 hours
c. Every 24 hours
d. Every 12 hours
c. Every 24 hours
The nurse is preparing to insert a nasogastric (NG) tube in a patient. Which step in the process indicates a need for further
education?
a. The nurse lubricates 4 inches of the tube prior to insertion.
b. The nurse marks the length of the tube with a marker for insertion.
c. The nurse measures the length of tube needed using the nose-earlobe-xiphoid
process.
d. The nurse applies clean gloves for the procedure.
b. The nurse marks the length of the tube with a marker for insertion.
The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which action by the nurse
indicates a need for further education?
a. The nurse clears the tube with air prior to discontinuing.
b. The nurse stops the tube feeding.
c. The nurse instructs the patient to cough while pulling out the tube.
d. The nurse clamps the tube while pulling it out.
c. The nurse instructs the patient to cough while pulling out the tube.
Based on research on aging, the nurse knows that improper nutrition may result in the onset of which specific diseases? (Select all
that apply.)
a. Type 2 diabetes
b. Atherosclerosis
c. Osteoporosis
d. Rheumatoid arthritis
e. Chronic asthma
a. Type 2 diabetes
b. Atherosclerosis
c. Osteoporosis
The nurse is helping a patient understand the difference between macronutrients and vitamins and minerals. The nurse identifies which items that should be included in the list of macronutrients? (Select all that apply.)
a. Water
b. Potassium
c. Starches
d. Fiber
e. Riboflavin
a. Water
c. Starches
d. Fiber
The nurse is providing dietary education to the patient to assist with inclusion of more complex carbohydrates in the diet. The nurse knows which foods would be beneficial to include? (Select all that apply.)
a. Green peas
b. Bananas
c. Beans
d. Potatoes
e. Apples
a. Green peas
c. Beans
d. Potatoes
The nurse is educating a patient about including more omega-3 fatty acids in the diet and knows which food sources should be included. (Select all that apply.)
a. Salmon
b. Flaxseed
c. Mackerel
d. Steak
e. Crayfish
a. Salmon
b. Flaxseed
c. Mackerel
The nurse is planning dietary education for the patient. What food labeling considerations should the nurse be aware of when
planning that education? (Select all that apply.)
a. Ask patient if food labels are read routinely.
b. Assess patient’s level of understanding of food labels.
c. Encourage patient to read the food labels.
d. Explain to patient all food labels are different.
e. Assess patient’s understanding of recommended daily allowance
a. Ask patient if food labels are read routinely.
b. Assess patient’s level of understanding of food labels.
c. Encourage patient to read the food labels.
e. Assess patient’s understanding of recommended daily allowance
The nurse knows that a deficiency in vitamin C can result in which conditions? (Select all that apply.)
a. Stiff joints
b. Osteopenia
c. Petechiae
d. Loose teeth
e. Bleeding gums
a. Stiff joints
c. Petechiae
d. Loose teeth
e. Bleeding gums
The nurse is teaching a patient about the impact of obesity and a high body mass index (BMI). The nurse identifies that as the BMI
increases, so does the risk for which conditions? (Select all that apply.)
a. Increase in blood pressure
b. Increase in HDL
c. Increase in total cholesterol
d. Development of atherosclerosis
e. Decrease in triglycerides
a. Increase in blood pressure
c. Increase in total cholesterol
d. Development of atherosclerosis
The nurse is completing a nutrition assessment on a patient. What are some important considerations? (Select all that apply.)
a. The nurse should include the patient’s cultural influences in the assessment.
b. The food diary accuracy is better for a 24-hour recall than a 3 to 5 day food
journal.
c. The nurse should be nonjudgmental in the nutritional review.
d. A consultation with a registered dietitian may be indicated.
e. A gathering of anthropometric measurements may be necessary.
a. The nurse should include the patient’s cultural influences in the assessment.
c. The nurse should be nonjudgmental in the nutritional review.
d. A consultation with a registered dietitian may be indicated.
e. A gathering of anthropometric measurements may be necessary.
The nurse is educating the patient about the risk of heart disease from metabolic syndrome and describes a cluster of which symptoms? (Select all that apply.)
a. Elevated blood glucose
b. High waist circumference
c. History of smoking
d. Hypertension
e. Elevation serum cholesterol
a. Elevated blood glucose
b. High waist circumference
d. Hypertension
e. Elevation serum cholesterol
The nurse is completing documentation after feeding a patient with aspiration precautions. Which items should the nurse document? (Select all that apply.)
a. Episodes of coughing or gagging
b. Hesitation or fear of eating
c. Amount eaten
d. Aspiration protocol used
e. Respiratory status
a. Episodes of coughing or gagging
b. Hesitation or fear of eating
c. Amount eaten
d. Aspiration protocol used
e. Respiratory status
When the nurse is caring for a patient receiving enteral feedings, which tasks can that nurse delegate to the UAP? (Select all that apply.)
a. Verify tube placement
b. Perform oral care
c. Administer tube feeding
d. Obtain vital signs and report results
e. Measure oxygen saturation
b. Perform oral care
c. Administer tube feeding
d. Obtain vital signs and report results
e. Measure oxygen saturation
The nurse is assessing an undernourished client. Which manifestation of the integumentary system should the nurse consider an expected finding? (Select all that apply.)
A. Muscle wasting
B. Petechiae
C. Spoon-shaped nails
D. Constipation
E. Dry brittle hair
B. Petechiae
C. Spoon-shaped nails
E. Dry brittle hair
During a home visit, the nurse is concerned that the family is experiencing food insecurity. Which observation made by the nurse caused this concern? (Select all that apply.)
A. The oldest daughter experiences abdominal cramps when ingesting milk products.
B. The mother prepares a meal for the children, but she claims a lack of appetite to avoid eating.
C. The mother is recovering from a second episode of pneumonia within 6 months.
D. The children are visibly thin and argue over the food remaining on the serving plate.
E. The kitchen cabinets contain a limited amount of food for a family of five.
B. The mother prepares a meal for the children, but she claims a lack of appetite to avoid eating.
C. The mother is recovering from a second episode of pneumonia within 6 months.
D. The children are visibly thin and argue over the food remaining on the serving plate.
E. The kitchen cabinets contain a limited amount of food for a family of five.
The nurse is demonstrating how to prepare a dinner menu using the MyPlate plan. Which food item should the nurse include? (Select all that apply.)
A. Steamed broccoli
B. One cupcake
C. Sliced peaches
D. Slices of roast beef
E. One glass of milk
A. Steamed broccoli
C. Sliced peaches
D. Slices of roast beef
E. One glass of milk
The nurse is planning to teach a class regarding factors that influence food choices. Which factor should the nurse include? (Select all that apply.)
A. Level of hunger
B. Availability
C. Convenience
D. Cost
E. Emotion
B. Availability
C. Convenience
D. Cost
E. Emotion
The nurse is caring for a patient newly diagnosed with celiac disease. When developing a teaching plan, which food should the nurse include as one to avoid? (Select all that apply.)
A. Rye
B. Eggs
C. Fruit
D. Wheat
E. Peanuts
A. Rye
D. Wheat
The nurse concludes that the client is demonstrating cardiovascular manifestations of undernutrition. Which assessment finding supports this conclusion? (Select all that apply.)
A. Low blood pressure
B. Lethargy
C. Amenorrhea
D. Slow respiratory rate
E. Irregular heartbeat
A. Low blood pressure
E. Irregular heartbeat
The nurse is planning to collect anthropometric data from a client who is being evaluated for undernutrition. Which information should the nurse include? (Select all that apply.)
A. Skinfold thickness
B. Capillary blood glucose level
C. Weight
D. Food allergies
E. Height
A. Skinfold thickness
C. Weight
E. Height
Which laboratory test measures protein levels? (Select all that apply.)
A. Serum prealbumin
B. Serum electrolytes
C. Lipid levels
D. Complete blood count
E. Serum albumin
A. Serum prealbumin
E. Serum albumin
The nurse is assessing a client for physical problems that affect food intake. Which factor should the nurse consider? (Select all that apply.)
A. Problems with dentition
B. Lactose intolerance
C. Use of supplements
D. Financial resources
E. Trouble swallowing
A. Problems with dentition
E. Trouble swallowing
A pregnant client tells the nurse that she has no idea how she is going to provide food for her two preschool-age children in addition to the new baby. Which nursing intervention should the nurse implement? (Select all that apply.)
A. Encourage the client to obtain additional employment.
B. Provide information about the Supplemental Nutrition Assistance Program (SNAP).
C. Discuss the financial support provided by the children’s father.
D. Recommend the Women, Infants, and Children (WIC) program.
E. Review the importance of adequate nutrition during pregnancy.
B. Provide information about the Supplemental Nutrition Assistance Program (SNAP).
D. Recommend the Women, Infants, and Children (WIC) program.
The nurse learns that a client follows a vegan diet. Which suggestion should the nurse give the client to ensure an adequate intake of vitamins and minerals? (Select all that apply.)
A. Put eggs into a salad every week.
B. Add tofu and lentils into the diet.
C. Include soft cheeses.
D. Increase the intake of citrus fruits.
E. Drink soy milk fortified with vitamin B12.
B. Add tofu and lentils into the diet.
D. Increase the intake of citrus fruits.
E. Drink soy milk fortified with vitamin B12.
The nurse notices that a client recently lost 10 pounds. Which question or statement should the nurse use to learn more about the weight loss? (Select all that apply)
A. “Do you eat enough?”
B. “I noticed that you have lost weight.”
C. “Tell me about how you do your food shopping.”
D. “Share with me what your daily eating habits look like.”
E. “You need to eat more dessert.”
B. “I noticed that you have lost weight.”
C. “Tell me about how you do your food shopping.”
D. “Share with me what your daily eating habits look like.”
Which tool is available to the nurse to assess a client’s eating habits? (Select all that apply.)
A. Waist-to-height ratio
B. Body mass index
C. Six-item Mini-Nutritional Assessment
D. Food frequency questionnaire
E. Food diary
C. Six-item Mini-Nutritional Assessment
D. Food frequency questionnaire
E. Food diary
Which statement accurately reflects that the client understands how to use the MyPlate plan?
A. “This seems too hard to remember. Can’t I just eat less?”
B. “You will send me a plate to use for my meals.”
C. “I will eat foods from each of the five food groups at every meal.”
D. “I will use the MyPlate handout to increase my portion size.”
C. “I will eat foods from each of the five food groups at every meal.”
The nurse is teaching a client about a newly prescribed iron supplement. Which information should the nurse include? (Select all that apply.)
A. Expect the stool to turn black.
B. Explain the need to increase fiber in the diet.
C. Explain how the supplement can cause constipation.
D. Suggest that the client avoid ingesting citrus fruits with the supplement.
E. Remind the client to ingest adequate amounts of fluid each day.
A. Expect the stool to turn black.
B. Explain the need to increase fiber in the diet.
C. Explain how the supplement can cause constipation.
E. Remind the client to ingest adequate amounts of fluid each day.
Which nursing intervention should be implemented for a client at risk of nutritional imbalances? (Select all that apply.)
A. Using nutritional supplements
B. Reducing body mass index
C. Promoting healthy eating habits
D. Providing nutritional education
E. Calculating caloric needs
C. Promoting healthy eating habits
D. Providing nutritional education
Which is the purpose of parenteral nutrition? (Select all that apply.)
A. To deliver calories during recovery from lap band or other bariatric surgical procedures
B. To supply nutrients when needs cannot be met through oral intake
C. To promote reducing the intake of fats and carbohydrates
D. To provide nutrients when foods cannot be consumed by mouth
E. To facilitate adherence to reduced-calorie eating plans
B. To supply nutrients when needs cannot be met through oral intake
C. To promote reducing the intake of fats and carbohydrates
While teaching the client about niacin, the client asks the nurse: “What brand of niacin is best?” Which is the nurse’s correct response?
A. “The brand is not important. Buy the one that costs the least.”
B. “I will ask the doctor which is the best brand.”
C. “Let me tell you about the side effects of the various brands.”
D. “Get the store brand.”
C. “Let me tell you about the side effects of the various brands.”
A client asks the nurse: “Is drinking a protein drink sufficient as a meal?” Which is the nurse’s most appropriate response?
A. “No, you should never drink protein drinks.”
B. “Tell me more about the protein drink you are using.”
C. “Add a piece of fruit to your breakfast and lunch routine.”
D ”Yes. That is fine.”
B. “Tell me more about the protein drink you are using.”
The nurse provides information about digestion to a group of older community members. Which statement should the nurse include in this teaching? (Select all that apply.)
A. Saliva production can increase.
B. Risk for gallstones can increase.
C. Taste can become less acute.
D. Tooth enamel can become more brittle.
E.
Pepsin production can increase.
B. Risk for gallstones can increase.
C. Taste can become less acute.
D. Tooth enamel can become more brittle.
The nurse prepares educational material about digestion for a group of new nursing employees. Which information should the nurse include about digestion that affects all ages? (Select all that apply.)
A. Growth and development depend largely on healthy nutrition and digestion.
B. Diarrhea is a primary disorder that is found in all age groups.
C. Nausea, vomiting, and diarrhea are common expressions of digestion disorders in all age groups.
D. Pyloric stenosis typically develops insidiously at all ages.
E. Celiac disease has a familial tendency.
A. Growth and development depend largely on healthy nutrition and digestion.
C. Nausea, vomiting, and diarrhea are common expressions of digestion disorders in all age groups.
E. Celiac disease has a familial tendency.
A client with prolonged diarrhea is concerned that the problem persists despite receiving treatment. Which response should the nurse make to address this client’s concern?
A. “Diarrhea is not life-threatening and you should not worry.”
B. “Diarrhea is a symptom of an underlying illness, not an illness itself.”
C. “Your diarrhea is most likely caused by a food allergy.”
D. “The healthcare provider is an expert in gastrointestinal disorders.”
B. “Diarrhea is a symptom of an underlying illness, not an illness itself.”
The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient’s bleeding?
a. Hemorrhoids
b. Bleeding gastric ulcer
c. Colon polyps
d. Perforated colon
a. Hemorrhoids
The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient?
a. Lack of knowledge related to prescribed diet modifications
b. Impaired nutritional intake related to poor appetite
c. Diarrhea related to excessive loss of fluid through stool
d. Anxiety related to incontinence with loose stools and need for clothing change
c. Diarrhea related to excessive loss of fluid through stool
The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse
indicates a need to contact the prescriber and question the order?
a. The patient has skin breakdown from loose stools.
b. The patient is constipated with last BM 3 days ago.
c. The patient is on a low-fiber, gluten-free diet.
d. The patient has painful bleeding hemorrhoids.
b. The patient is constipated with last BM 3 days ago.
The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his
breakfast and is still nauseated. Which action by the nurse is the highest priority?
a. Provide oral care after each episode of emesis.
b. Apply a skin barrier to the patient’s perineal area.
c. Check the patient for fecal impaction.
d. Administer antiemetic medication with a sip of water.
c. Check the patient for fecal impaction.
The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?
a. The patient has bowel sounds x 4 quadrants and is passing gas.
b. The patient has no nausea, and abdominal pain is minimal.
c. The patient feels hungry for chicken soup and hot tea.
d. The patient’s nasogastric tube was discontinued the previous day.
a. The patient has bowel sounds x 4 quadrants and is passing gas.
The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient?
a. Impaired skin integrity r/t localized skin irritation from liquid stool
b. Social isolation r/t potential leakage of stool from ostomy appliance
c. Lack of knowledge r/t care and maintenance of ostomy appliance
d. Disturbed body image r/t presence of stoma and altered elimination
a. Impaired skin integrity r/t localized skin irritation from liquid stool
