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Foundations Nursing
Foundations Nursing set 9
| Question | Answer |
|---|---|
| The nurse is describing effects of pain to a patient who is getting ready for surgery. Which statement made by the nurse indicates proper understanding of the effects of pain? | “You may experience increased blood pressure.” |
| A patient with diabetes is being seen in the emergency department for a broken arm. He states that he is in a lot of pain. The nurse understands that pain could have which effect on the patient’s blood sugar? | Increased blood sugar |
| A nurse is caring for a patient on the oncology floor. The nurse understands that which observation indicates the patient is in pain? | The patient’s urine output has decreased from its normal baseline. |
| The nurse is teaching a patient’s family about the effects of pain. Which statement made by the nurse indicates proper teaching? | “When a patient is in chronic pain, the parasympathetic nervous system responds.” |
| A nurse is caring for a patient with a burn. When conducting the pain assessment, which action should the nurse perform first? | Take the patient’s vital signs. |
| A nurse is performing a pain assessment for a trauma patient. Which questions should the nurse include in the pain assessment? | “Where is the pain located?” “Does the pain radiate anywhere?” “What makes the pain worse or better?” |
| A new nurse is trying to do a pain assessment. The charge nurse reminds the new nurse to use SOCRATES. The new nurse understands that the “T” in SOCRATES stands for what? | Time course |
| nurse is talking with a patient regarding the patient’s pain. The nurse performed the SOCRATES set of questions. The nurse understands that which additional question would be relevant to the pain assessment? | “What are your past pain experiences?” |
| working in ER office. patient possible broken ankle, experiencing a lot of pain. The nurse obtains his vital signs and watches him grimace every time his foot is moved. The ankle is edematous. patient says pain 9/10. considered subjective data? | Pain scale 9 out of 10 |
| A nurse is performing a pain assessment on a patient who is complaining of chest pain. The nurse understands that which question is appropriate to ask the patient? | Where is the pain located?” |
| The nurse is talking to a 50-year-old patient about his chronic back pain. Which questions would be appropriate for the nurse to ask? | “Have you had similar pain in the past?” “What are your past experiences with pain?” “What do you use to deal with your discomfort?” “What effect does the pain have on your activities of daily living?” |
| nurse is taking care of a 3-month-old infant who recently had abdominal surgery. The nurse is concerned that the patient may be in pain. Which action made by the nurse indicates proper knowledge of pain assessment? | Using the Neonatal Infant Pain Scale |
| A nurse is caring for a patient with kidney stones. The nurse asks the patient to describe the pain on a scale of 0-10.The patient rates the pain a 5. How would the nurse classify this pain? | Moderate pain |
| A nurse is assessing pain in a 4-year-old patient who has a femur fracture. Which pain assessment tool would be recommended for this patient? | Universal Pain Assessment Tool |
| nurse completed pain assessment on 16-year-old hospitalized post-op for open-heart surgery. describes the pain as “constant aching” and is rated 8 on the 0-10 pain scale. Which action made by the nurse indicates proper understanding of pain assessment? | Looking in the patient’s chart for pain medication that was ordered, and obtaining an order for pain medication from the provider if none has been prescribed |
| nurse is caring for a patient diagnosed with diabetes who has recently undergone an above-the-knee amputation (AKA). When assessing this patient’s ability to perform self-care, the nurse should use what type of information? | Subjective data Objective Data Patient's answers |
| A nurse is performing an initial assessment on a recently admitted patient. What finding warrants an immediate call to the healthcare provider? | Presence of pediculosis |
| A nurse is reviewing the steps of performing a personal care assessment on a patient requiring bathing assistance. Which step should the nurse perform first? | Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice. |
| What are possible signs of poor hygiene? | Body odors tangled and matted hair excessively long and dirty toenails |
| The nurse is asking a patient hospitalized with acute pancreatitis questions about the patient’s self-care capabilities. Which are examples of questions that the nurse may ask to assess the patient’s ADLs? | Do you always make it to the bathroom on time? How often do you take a bath or shower? Can you bathe yourself without help? |
| nurse is caring for a patient who was involved in a motor vehicle accident (MVA). The patient did not sustain any oral trauma. How should the nurse document the normal assessment of this patient’s oral cavity? | Pink and moist oral cavity without sores |
| An immobile patient is running a fever. The nurse suspects the patient has a decubitus ulcer. The nurse observes the patient’s skin for signs of infection, which may include what symptoms? | Redness Swelling Drainage |
| older adult patient with arthritis has difficulty using his hands to button clothing, holding an eating utensil or toothbrush, and turning a door lock. In regards to this patient’s discharge from the hospital to home, it is the nurse’s responsibility to: | Assist the patient with community referrals. |
| Based on the answers given during an initial health history, the nurse suspects that the patient has a fungal infection in his toenails. What physical exam findings would confirm this suspicion? | Thickening of the nail |
| The nurse notices that a patient with a complicated health history has halitosis when the patient speaks. The nurse knows that the patient’s halitosis could be caused by ________________? | Diabetes Poor oral hygiene medications Infections of the oral cavity |
| A nurse is developing a care plan for a chronically bedridden patient with a nursing diagnosis of Toileting Self-Care Deficit who is being discharged. Which goal is appropriate for this patient? | Locate appropriate homecare assistance. |
| The nurse is watching nursing students as they perform a chair bath. What activity, if observed by the nurse, should be corrected? | Washing the skin and hair before performing the assessment of patient's skin, hair, and nails. |
| The nurse is assessing a teenager’s oral cavity as part of the admission assessment. Which finding, if observed during the assessment, should the nurse refer the patient to the dentist for further care? | Broken teeth |
| A nurse is initiating a care plan for a newly admitted hospitalized patient who is unable to perform basic ADLs independently. What intervention should be listed in the care plan? | Daily bed bath and assistance with hygiene, and as needed. |
| A nurse is caring for a patient with a severe infection of the gums. What is one possible nursing diagnosis based on the patient’s “at risk” status? | Risk for altered nutrition |
| A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? | The patient rates his pain a 7 on a scale of 0 to 10. |
| What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain? | "Let me know at least 30 minutes before you transport her so I can administer her analgesics." |
| Which observation indicates that a patient's pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? | The patient rates her current pain as 3 out of 10 on the pain rating scale. |
| A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient? | Performing neck, back, and shoulder exercises prescribed by a physical therapist |
| The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? | The absence of physiological signs and symptoms is associated with chronic pain. |
| patient no medical conditions is says she is tired all the time and unable to stay awake. falling asleep while at work, vivid hallucinations upon awakening, brief episodes of paralysis at beginning of sleep. nurse suspects patient suffering condition? | Narcolepsy. |
| A nurse is teaching a patient about the effects of medication on sleep. Which statement shows a need for further teaching? | "Barbiturates increase REM sleep." |
| Which patient has the greatest risk of developing obstructive sleep apnea (OSA)? | Obese, adult male smoker with a large neck circumference. |
| How are sleep deprivation and narcolepsy similar? | Both disorders can cause hallucinations. |
| patient with liver disorder unable to function at work for past few months due to excessive daytime sleepiness. The patient sleeps nine hours each night, but still has trouble getting up for work. What condition does the nurse suspect for this patient? | Hypersomnia. |
| The nurse is discussing night terrors with a patient. Which statement made by the patient shows proper understanding? | "Fever tends to trigger night terrors." |
| A nurse is teaching a parent with a child diagnosed with nocturnal enuresis about the disorder. Which statement(s) by the parent shows a need for further teaching? | does not watch scary movies at night she will not wet the bed." ages 3-7, the ages when bedwetting is common." cannot control her bladder; there must be something wrong with her." not need behavioral therapy for her bedwetting problem." |
| The nurse is teaching a patient about secondary sleep disorders. Which statement by the patient shows effective teaching? | -"Sinus drainage may cause difficulty breathing." -"Shortness of breath impairs the ability to sleep." -"End-stage renal disease leads to daytime sleepiness." |
| A patient recovering from a serious illness, with a history of anxiety, complains having difficulty in sleeping. What additional mental health disorder should the nurse suspect in this patient? | Depression. |
| What night-time snack is appropriate for a patient with a history of insomnia? | Graham crackers. |
| Which long-term medication(s) should be prescribed for a patient who has a history of insomnia? | Lunesta. |
| nurse is caring for a patient who is having difficulty sleeping. The patient states that he is going through a lot of stress since he changed jobs, and is considering moving out of the city to the country. Which statement by the nurse is appropriate? | "Moving to a new location, even a quieter one, may worsen your insomnia." |
| nurse caring for hospitalized patient w/insomnia. patient fell asleep at 5:00, been asleep for 30 mins. What time would be appropriate for nurse to return, provide care for patient, while allowing him the minimum time to complete all of his sleep cycles? | 7:10. |
| A nurse caring for a hospitalized patient with insomnia should implement which recommendation to help the patient sleep? | Keep the patient's door closed. |
| Which patient(s) would be most likely suffer from sleep disturbances? | -Young adult female with marital problems. -Older adult male who recently lost his wife in death. -Child who is spending the summer away from home at camp. -Adult female caring for a family member with a chronic illness. |
| Which statements about point-of-care technology are true? | In some situations, point-of-care data collection decreases time spent on documentation. Point-of-care technology reduces potential for errors. |
| Which statements about point-of-care technology are true? | Electronic point-of-care data collection allows immediate patient information access by health care team members. |
| A patient’s blood pressure and temperature are examples of which nursing informatics concept? | Data. |
| Which fields of science are encompassed within the broad academic field of informatics? | -Social science. -Computer science. -Information science. |
| Why is IT training important for health care staff? | -Enables staff to optimize patient outcomes through appropriate use of IT tools. |
| Which statements related to health care IT are valid? | Facility policy regulates and defines the acceptable use of IT within a facility. -Health care staff today must develop skills in the use of certain technologies. |
| Which examples describe the use of telehealth? | -Nurses having audio and visual contact with a patient in the home. -Clinicians and specialists conducting consultations remotely via an Internet connection. |
| In which areas have the application of information technology in health care resulted in major improvements? | -Patient safety. -Research access. -Networking. |
| How do computerized decision support systems (DSSs) contribute to patient safety? | -Includes safe practice alerts. -Assists in determining correct diagnoses. -Assists in selecting an appropriate medication. |
| What is networking in the context of information technology? | Use of technology to interact with individuals and resources. |
| What is the goal of the eHealth Code of Ethics for health care sites and services? | Ensure that people can use internet resources confidently to manage health. |
| Which statements regarding HIPAA are true? | -HIPAA outlines legal penalties for nurses who breach security of health care data. -Nurses are legally and professionally responsible for understanding HIPAA. -HIPAA sets standards for how confidentiality of health care information must be maintained. |
| How are security violations in electronic health records usually detected? | The system tracks and records the user's electronic trail within the record. Security staff can review the trail. |
| Which type of nursing informatics specialty competency is a nurse using when working with a committee to evaluate the ethics of implementing a new patient-tracking software program? | Leadership. |
| Which skill demonstrates information literacy? | Ability to properly use the electronic health records to pull up information from a patient's last visit. |
| What does/did the TIGER initiative do for nursing informatics? | dentified a set of nursing informatics skills needed by all nurses in current practice. |
| Clinical data elements for use in all nursing settings | Nursing Minimum Data Set |
| Nursing diagnoses | NANDA international |
| Diagnoses, interventions, and outcomes | Clincal care classification |
| Nursing administrative data elements for use in all nursing settings | Nursing Management Minimum Data Set |
| Why is the use of standardized nursing terminology important when treating a patient as part of a multidisciplinary nursing team? | Allows all nurses to use the same vocabulary to facilitate communication |
| Why does the use of computerized data collection and research in health care increase the need for standardized nursing terminologies in documentation? | Computers cannot make associations between different written descriptions meaning the same thing without standardized terminologies. |
| Which question should be asked about an online health information website to verify its content? | is this information found in other sources? |
| Determining a website’s date of last update evaluates which criterion for credibility? | currency |
| Which questions should be asked about an online health resource to determine the objectivity of the resource? | is there evidence bias in the website? what are the goals of the website? is bias explicit or hidden? |
Created by:
colby.caswell