Test 2 LP 4,5,6
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| A patient has been on contact isolation for 4 days because of a gastrointestinal infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Nursing measures to reduce sensory deprivation include: (Sel | Helping him to a chair or bringing a flower into the room, & Sitting down, speaking, touching, and listening to his feelings and perceptions.
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| The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which strategy is not effective in enhancing a patient’s impaired vision? | Use of fluorescent lighting
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| A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitate communication with her? | Face the patient when speaking; speak slower and in a normal volume.
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| The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which of the priority interventions enables the patient to function safely with existing deficits and continue a normal lifestyle? | Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources.
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| A 74-year-old patient who has returned to the nursing home following surgical removal of bilateral cataracts reports feeling a little uncertain about walking by herself. Which of the following approaches do you use to assist her with ambulation? | Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles
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| Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: | Take precautions when involved in activities associated with high-intensity noises.
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| The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient would indicate that additional teaching is needed? | “I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."
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| The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination the patient ’ s temperature is 99.6°F (37.6°C), heart rate 80 beats/min, respiratory rate 18 breaths/min, and blood pressu | A hearing deficit.
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| When communicating with a patient who has expressive aphasia, the highest priority for the nurse is: | To offer pictures or a communication board so the patient can point.
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| A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. Interventions the nurse uses to reduce loneliness include: (Select all that apply | Providing information about local social groups in the patient’s neighborhood. & Recommending that the patient consider making living arrangements that will put him closer to family or friends.
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| A nurse is performing an assessment on a patient admitted to the emergency department with eye trauma. The nurse’s priority interventions include which of the following? (Select all that apply.) | Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching. & Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye
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| Which patient is most likely to experience sensory deprivation? | A 14-year-old girl isolated in the hospital because of severe immune system suppression
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| The medical record of an older adult reveals a stroke affecting the right hemisphere of the brain. Which of these assessment findings should the nurse expect to find? (Select all that apply.) | Visual spatial alterations such as loss of half of a visual field. & Inattention and neglect, especially to the left side
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| A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can’t hear anything.” Which of the following teaching strategies should not be implemented? | Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, “Is this voice clear?”
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| When assessing a 45-year-old patient’s sensory status, which of the following assessment findings does the nurse consider a normal part of aging? | Presbyopia and the need for glasses for reading
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| The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? | Feedback
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| Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? | Coach her to give herself positive messages about her ability to do this
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| The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? | The patient is short of breath.
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| You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? | Talk with him about his favorite hobbies
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| The nurse states, “When you tell me that you’re having a hard time living up to expectations, are you talking about your family’s expectations?” The nurse is using which therapeutic communication technique? | Clarifying
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| Which of the following statements would be most likely to block communication? | “Why do you always put so much salt on your food?”
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| You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? | Move to her bedside, get her attention, and repeat the question while facing her
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| You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, “Why don’t you figure it out?” What would be the best response? | When you brush me off like that, it takes me even longer to do my job.”
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| When the nurse takes the patient’s nursing history, he or she sits: | 18 inches to 4 feet from the patient.
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| When working with an older adult, the nurse remembers to avoid: | Shifting quickly from subject to subject.
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| The statement that best explains the role of collaboration with others for the patient’s plan of care is which of the following? | The professional nurse works with colleagues and the patient’s family to provide combined expertise in planning care.
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| Identify behaviors that foster the development of trust. (Select all that apply.) | Answer the call light promptly.; Answer questions honestly.; Demonstrate competence when doing treatments.
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| A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? | Obtains an interpreter to facilitate communication of medication information
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| Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) | Pulling the curtain to provide privacy; Offering to discuss information about her condition; Sitting quietly by her bed and hold her hand
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| Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? | Deflect your eyes downward to show respect
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| A manager who is reviewing the nurses’ notes in a patient’s medical record finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions does the manager give to the staff nurse | Enter only objective and factual information about the patient.
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| A new graduate nurse is providing a telephone report to a patient’s health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse’s preceptor to intervene? The new nurse: | Gives a newly ordered medication before entering the order in the patient’s medical record.
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| As you enter the patient’s room, you notice that he is anxious to say something. He quickly states, “I don’t know what’s going on; I can’t get an explanation from my doctor about my test results. I want something done about this.” Which of the following i | The patient stated that he felt frustrated by the lack of information he received regarding his tests.
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| You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, “I’ve heard a lot about these HIPAA regulations in the news lately. How will they affect my care? | HIPAA provides you with greater control over your personal health care information.
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| A patient asks for a copy of her medical record. The best response by the nurse is to: | Indicate that she has the right to read her record.
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| Which of the following charting entries is most accurate? | Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
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| On the nursing unit you are able to access a patient’s medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type | Electronic health record.
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| You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) | The patient’s name, age, and admitting diagnosis; Allergies to food and medications; That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
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| You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: | Documented medication given by another nursing student.
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| A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? | “CPOE reduces transcription errors.
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| A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed | Clinical decision support system
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| A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine ex | Health perception–health management pattern
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| Which of the following are examples of data validation? (Select all that apply.) | The nurse assesses the patient’s heart rate and compares the value with the last value entered in the medical record.; The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.
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| A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? | Is anything else bothering you?
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| The nurse is assessing the character of a patient’s migraine headache and asks, “Do you feel nauseated when you have a headache?” The patient’s response is “yes.” In this case the finding of nausea is which of the following? | A concomitant symptom
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| During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) | Physical examination with auscultation of the lungs; Medical record summary of x-ray film findings
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| The nursing diagnosis readiness for enhanced communication is an example of a(n): | Health promotion nursing diagnosis
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| A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: | Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
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| The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? | Risk for aspiration
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| Setting a time frame for outcomes of care serves which of the following purposes? | Indicates when the patient is expected to respond in the desired manner
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| A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? | During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.
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| Which outcome allows you to measure a patient’s response to care more precisely? | The patient’s wound will reduce in size to less than 4 cm (1 ½ inches) by day 4.
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| A nurse identifies several interventions to resolve the patient’s nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) | Turn the patient regularly from side to back to side.; Apply a pressure-relief device to bed.
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| When does implementation begin as the fourth step of the nursing process? | After the care plan has been developed
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| The nurse enters a patient’s room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? | Protecting a patient from injury
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| When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient’s tolerance, this is an example of what type of implementation skill? | Psychomotor
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| A goal specifies the expected behavior or response that indicates: | Resolution of a nursing diagnosis or maintenance of a healthy state.
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| Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) | Redefine priorities; Continue intervention;
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| Which of the following statements correctly describe the evaluation process? (Select all that apply.) | Evaluation is an ongoing process.; Evaluation involves making clinical decisions.; Evaluation requires the use of assessment skills.
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