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Foundations Nursing set 8

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Question
Answer
An older adult male is complaining of chest pain. The nurse is able to identify that the patient is experiencing acute pain by asking which question?   show
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t eight months post-knee surgery the patient still complains of tenderness of the knee and finds it difficult to walk without feeling a tingling pain. Which nursing diagnosis is priority for this patient?   show
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A nurse can adequately classify pain by asking the patient questions focusing on which factors?   show
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show Cancer, numbness due to chemo, three months  
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show Somatic pain  
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show Inflammatory Bowel Disease  
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An older adult patient presents to the emergency department complaining of sharp jaw pain. The triage nurse knows this is one of the classic signs of a heart attack. What type of pain does the triage nurse understand this patient is experiencing?   show
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show Radiating pain  
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nurse caring for patient with osteosarcoma. patient recently had surgery and is now complaining of pain around surgical site in addition to dull pain in leg. nurse suspects that patient has chronic pain, but is currently experiencing which type of pain?   show
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show Phantom limb pain  
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When caring for a psychiatric patient who is complaining of headaches with no relief, a nurse asks a nursing student how psychogenic pain may present. Which response indicates that the nursing student understands what psychogenic pain is?   show
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Which medication is a woman more likely to be prescribed for pain?   show
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The triage nurse in the emergency department realizes that which patient is more likely to report being in pain?   show
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show Asian females  
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The nurse is caring for a one-year-old with fever. He is crying continuously and cannot be comforted with food or by being held. What are the most appropriate actions for the nurse to do next?   show
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How does soap work?   show
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What is the primary purpose of appropriate hand hygiene   show
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show The nurse's hands are not visibly soiled  
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The nurse is discussing the guidelines for proper hand hygiene with nursing assistive personnel (NAP). Which statement made by NAP requires follow-up by the nurse?   show
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Which patient is at the greatest risk for hospital-acquired infection (HAI)?   show
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A patient with Alzheimer’s disease is being cared for in the medical-surgical unit. As pain assessments are conducted on a patient with a cognitive disorder, what is the nurse mindful of?   show
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show Grimace  
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show Pain is what the patient says it is.  
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show Administration of pain medication  
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patient with diabetes develops an infected wound on the plantar aspect of the foot. The patient reports that he never felt any pain or discomfort related to the wound. Which pain response is lacking in this type of injury?   show
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patient has suffered burn injuries related to a house fire, and is in the burn center for pain control and dressing changes. What function does pain serve when it is associated with a thermal injury?   show
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show Mechanical  
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show Burn  
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show Sensory-discriminative aspect  
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four steps in the nociception process.   show
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four steps in the nociception process.   show
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The nurse is conducting a pain assessment on a patient in the oncology unit. The patient is asked to describe the intensity of pain that she is willing to withstand. How is this documented?   show
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During the modulation process of nociception, which endogenous opioid has an influence on the emotional perception of pain?   show
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nurse conducts comprehensive pain assessment, patient asked to describe quality of pain. patient describes pain as sharp and acute. Which phase of the nociception process is responsible for the type of pain impulse that is being detected by the patient?   show
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show Bradykinin Histamine Cytokines  
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caring for patient with chronic back pain. feels that he has an increase in back pain when he is experiencing stress. He wishes to practice relaxation techniques to decrease the perception of pain. Which pain theory is this practice associated with?   show
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The patient has been diagnosed with obstructive sleep apnea (OSA) experiencing daytime sleepiness and excessive snoring. Which are the best nursing diagnoses for this patient?   show
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show Sleep Deprivation related to frequent awakening of infant as evidenced by parent complaints of lack of sleep. Disturbed Sleep Pattern related to being awakened several times each night.  
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show Readiness for Enhanced Sleep as evidenced by request for sleep hygiene practices at home  
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Which nursing diagnostic label is most appropriate for a patient who sleepwalks?   show
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show Sleep Deprivation  
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nurse prepares the patient for discharge from the hospital. One of the nursing diagnoses for this patient is Readiness for Enhanced Sleep as evidenced by request for sleep aids. Which goal is appropriate for this patient?   show
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What is an appropriate long-term goal for the nurse to include in a plan of care for a patient who is suffering from Insomnia related to psychological job stress?   show
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show Patient will sleep for at least 90 minutes at a time during hospitalization.  
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Which goal statement is appropriate when planning care for a patient admitted to the hospital with a concussion after falling while sleep walking, who is currently alert and oriented?   show
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Which goal statement should the nurse to include in the plan of care for a patient with a nursing diagnosis of Disturbed Sleep Pattern related to lighting and noise in the hospital?   show
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Which goal statement should the nurse include in the plan of care for a patient with the nursing diagnoses Disturbed Sleep Pattern and Fatigue?   show
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Which is the best goal statement for the nurse to include in the plan of care for an older patient with the nursing diagnosis of Fatigue, who feels sleepy during day time inspite of getting enough sleep in the night?   show
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Which are risk factors for the nursing diagnosis Risk for injury related to sleep?   show
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A nurse is caring for a patient with scleroderma. The nurse spent time with the patient and used great communication skills. Why is effective communication so important in nursing practice?   show
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show Feedback is important to ensure the correct interpretation of the message. Senders initiate communication by encoding their own thoughts and feelings. Channels of communication can be delivered through all five senses.  
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A graduate nurse has a question about the communication process. Which of these is the first element of the process?   show
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A nurse is teaching a high school student about the five senses as channels of communication. Which choice presented to the student is an example of an auditory channel assessment?   show
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Which option is a type of verbal communication used by a successful nurse?   show
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Which situation shows an example of nonverbal communication when the nurse is assessing the patient?   show
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Why is it important for one nurse to verify documentation with another nurse?   show
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What are the five phases of small group communication?   show
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show Performing  
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show Brings out personality conflicts that require resolution to progress.  
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show What actions should be initiated for this problem?  
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show Recent past medical history of a distal radius fracture  
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show Patient outcomes are improved.  
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Professor Brown tells Susan the assignment is due today.   show
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show Receiver  
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Susan uses email to ask Professor Brown about the assignment.   show
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show Message  
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Susan, a nursing student, has prepared a scenario for Professor Brown to teach the six key elements of communication. Match the element of the communication process with the example of the element. Susan   show
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show Referent  
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show Interpersonal  
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show Intrapersonal  
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show small group  
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A nurse is asked to serve as a professional expert on health care issues.   show
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show Situation  
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Never used to have MRSA originate at Cardiac Recovery ward   show
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Need to find source of MRSA and weak link to contamination   show
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show Recommendation  
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show Writing nursing notes at the nurse's station  
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show Visiting a patient to provide home health care  
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show "You seem uncomfortable."  
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The male nurse is caring for a female patient from the Middle East. The patient will not speak to the nurse nor let him perform a physical assessment. What action should the nurse take?   show
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show Auditory channel  
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The nurse needs to communicate the patient’s plan of care to the provider. Which responses are appropriate interprofessional communications from the nurse?   show
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show The patient does not understand the information.  
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A group working with a patient who has diabetes tries to resolve a wound on the patient that will not heal. What is the correct phase of this group?   show
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show Educating patients and the community in a public forum  
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show "I am going to ask you questions about your health history." "I have developed a plan of care based on the information you gave me in your history."  
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The nurse is asking the patient about his personal health history. Which question is an effective verbal technique for getting more information?   show
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caring for patient had a heart attack. no visitors and is about to undergo a heart catheterization in one hour. When the nurse comes into the room, the patient yells because the nurse is late with his medication. What is the best response from the nurse?   show
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show MJ in Room 16 is short of breath. She is 79 years old with heart failure and diabetes. Her respirations are 28, and her blood sugar is normal. I believe she might be in fluid overload and I recommend diuresing her."  
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show Sit down with the patient and verbally answer all her questions regarding her medications.  
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show "What are your concerns about the chemotherapy?"  
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A nursing student is giving a report on the different types of effective nonverbal communication. Which statement made by the student suggests that she understands effective nonverbal communication?   show
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show Blood pressure and heart rate  
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show Ineffective Coping  
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show Readiness for Enhanced Comfort  
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The nurse provides a patient with a pain assessment scale. The patient reports a pain level at 8 of 10. What does the nurse know is true regarding this statement?   show
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show Dull or aching pain is a subjective finding  
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show Massage therapist  
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show Blood pressure and heart rate  
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child w/ moderate-to-severe headache related to concussion tells nurse that he cant concentrate in school. treated nine months concussion symptoms reports he sleeps eight hours each night. Which is the most appropriate nursing diagnosis for this patient?   show
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show Readiness for Enhanced Comfort  
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The nurse provides a patient with a pain assessment scale. The patient reports a pain level at 8 of 10. What does the nurse know is true regarding this statement?   show
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Following abdominal surgery, the nurse assesses her patient for pain. Which is true regarding pain assessment?   show
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show Massage therapist  
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Which duty can the nurse delegate to the UAP to care for a patient who is experiencing pain?   show
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nurse caring for patient is prescribed pain med and anxiety med. The lowest pain rating the patient reports during the shift is 7/10. With whom should the nurse collaborate to offer non-pharmacologic therapies to the patient?   show
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nurse is helping a patient set goals related to pain. The patient requests for the pain to decrease from 8 of 10 to 2 of 10 on a 0 to 10 numeric scale three days after surgery. Which goal will the nurse identify for the patient?   show
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show Tolerance  
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Which is most indicative of chronic pain that is not improving?   show
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show Tachycardia  
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Which are signs of pain in a 12-year-old child who fell off of a horse and has a fractured spleen?   show
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show Administration of acetaminophen/oxycodone (Percocet)  
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What do massage therapists and music therapists have in common?   show
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show Tolerance  
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What are the three parts of the nursing diagnosis?   show
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show Child refrains from sharing personal items with school classmates.  
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show Present capabilities Supportive resources Family involvement Personal care supplies  
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show Prioritizes patient's hygiene-related nursing diagnoses Sets realistic personal care goals with the patient  
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Which hygiene and personal care nursing diagnosis is correctly stated?   show
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show Assessing patient self-care abilities  
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show Hygiene Self-Care Deficit  
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A patient is unable to perform self-care activities. Following collaboration with the UAP, which activities can be delegated?   show
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Following collaboration about a patient’s hygiene needs, which activities can be delegated to the UAP?   show
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show Delegating nurse  
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Why is it important to set measurable hygiene and personal care goals for patients?   show
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show Patient will shower independently by the end of one month.  
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show who, what, when  
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show Accommodate the patient's wishes  
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When is it appropriate for family members to be involved in setting hygiene and personal care goals for patients who can communicate their own needs and desires?   show
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Which action by the nurse indicates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care?   show
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show Personal grooming Partial bath Denture care Hair care  
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What piece of clothing is best to remove when looking for excoriations?   show
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show Small mirror  
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Which patient is most at risk for skin ulcers?   show
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Which patient would least likely be at risk for skin ulcers?   show
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show Red and scaly lesions  
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When reviewing a patient’s chart, the nurse notes the documentation of a pressure ulcer. What would the nurse expect to find upon assessment?   show
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A patient arrives at the emergency room with a puncture wound. What type of injury best describes a puncture wound?   show
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show A. Washing hands with soap and water prior to treatment B. Using gloves C. Using sterile pads while trying to control the bleeding  
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Which statement, if made by a chemotherapy patient, indicates the need for further education?   show
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The nurse is caring for a patient with oral cavity sores. Which food item would the nurse advise the patient to avoid?   show
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show B. Banana C. Gelatin D. Applesauce  
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Which physical trait might a nurse find when treating a patient with gingivitis?   show
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A patient complains of chronic bad breath. What is the best advice to help the patient?   show
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show D. "Changing my toothbrush every year is important."  
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Which assessment data would indicate a potential complication associated with the skin of a patient?   show
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show A. "Assist your child with checking for head lice regularly." B. "Have the child tell you if his head itches." C. "Look for any patches of hair loss."  
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show A. Missing teeth B. Halitosis D. Dry mouth  
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show B. Decreased elastin  
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Which interventions might the nurse implement in order to prevent pressure ulcers?   show
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Which age-related skin issue increases the risk of pressure ulcers?   show
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Which nursing diagnosis best displays sensitivity towards the needs of the patient and family?   show
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show Give a warm bath b. Read a bedtime story c. Provide a favorite toy d. Play soft, soothing music  
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Which non-pharmacologic intervention should the nurse initiate for a patient who is having difficulty falling asleep due to mild back pain?   show
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show Yoga  
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show Enlisting the help of friends Dealing with problems at a certain time each day Using relaxation techniques  
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show "I should drink several glasses of red wine in the evening to enhance the sleep I get overnight."  
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The nurse is providing care to a patient diagnosed with restless leg syndrome (RLS). Which nonpharmacologic nursing intervention is most appropriate to promote rest for this patient?   show
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Which information should the nurse instruct a patient to include in a sleep diary?   show
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show Assisting the patient to the toilet prior to bed  
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A patient who recently moved to a new location is unable to sleep and asks the nurse about over-the-counter (OTC) medications for sleep. Which drug classification should the nurse suggest to this patient to promote sleep?   show
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Which supplements should the nurse include in a teaching session for a patient who is experiencing chronic insomnia?   show
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A nurse is teaching a patient information related to the safe administration of common sleep medications. Which statement by the patient indicates need for further teaching from the nurse?   show
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