Multidimensional Care I Exam 1, Exams of Nursing

Download Multidimensional Care I Exam 1 and more Exams Nursing in PDF only on Docsity! Multidimensional Care I Exam 1 MDC 1 Exam 1 1. A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine. 2. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization 3. A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver 4. A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (Select all that apply.) A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch 5. A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply.) A. Art therapy B. Acupressure C. Yoga D. Therapeutic touch E. Biofeedback 6. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) 14. electronic safety monitors (chair or bed sensors) 13. What is a nurse's concern with patients using their call lights? That nurses respond in a timely manner...otherwise the patient may become impatient and attempt to move themselves 14. What must be completed before performing first aid? primary survey 15. Name the nursing interventions for BLEEDING - apply pressure to wound site (home) - DO NOT remove impaling objects, stabilize the object (home) - IV volume replacement with blood or volume replacement (hospital) 16. The acronym RICE is used to manage sprains, what do the letters stand for? R - refrain from weight bearing (also known as "rest") I - apply ice to decrease inflammation C - apply a compression dressing to minimalize swelling E - elevate the affected limb 17. Name the nursing interventions for BURNS - remove the agent - smooth any flames present - cover the client and maintain NPO status - elevate the extremities - Stop, Drop, and Roll (home) - call 911 (home) - perform H to T assessment (hospital) - administer fluids and tetanus toxoid (hospital) 18. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A. Hypotension 19. Name the nursing interventions of INFANT SUFFOCATION - place infants on back to rest - never leave alone in bathtub - do not place anything in the crib; remove mobiles when baby can sit up - keep latex balloons away - toilet lids down, bathroom doors closed - make sure slats on crib are a safe distance 20. Name the nursing interventions of INFANT BURNS - test the temperature of formula and bath water - place pots on back burner and turn handle away from the front of the stove - supervise the use of faucets - cover electrical outlets - apply sunblock SPF 30 or higher 21. Name the nursing interventions of INFANT MOTOR VEHICLE INJURY - rear-facing car seat - car seat with 5-point harness - forward facing seat after the age of 2 or when they meet the height/weight requirements 22. Name the nursing interventions of PRESCHOOLERS/SCHOOL AGE CHILDREN AND FIREARMS - keep firearms unloaded, locked up, and out of reach - teach to never touch a gun or stay at a friend's house where a gun is accessible - store bullets in a different location from guns 23. Name the nursing interventions of PRESCHOOLERS/SCHOOL AGE CHILDREN AND POISON - teach child about the hazards of alcohol, cigarettes, and prescription, non-prescription, and illicit drugs - keep potentially dangerous substances out of reach - have the poison control hotline available 24. Name the nursing interventions of PRESCHOOLERS/SCHOOL AGE CHILDREN AND MOTOR VEHICLE INJURY - use booster seats for children under 4'9" tall and weigh less than 40 lb - use seatbelt properly after booster seat - teach child safety rules of the road 25. If a patient asks for "last rights" what religion is that associated with? Catholicism 26. _______ is a challenge to belief systems or spiritual well-being. It often arises as a result of catastrophic events. The client can display hopelessness and decreased interactions with others. spiritual distress 27. What are Christian scientists’ views on illness and health? - Health care beliefs often correlate with modern medical science. 36. A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client." B. "I will ask the client if they want to schedule some times to pray during the day" 37. A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." 38. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A. Hypotension 39. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, they should be safe in the bathtub." C. "I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." D. "Once my infant starts to push up, I will remove the mobile from over the crib." 40. Name some benefits of bathing patients - cleanse the body - stimulate circulation - provide relaxation - enhance healing 41. Name some nursing considerations for bed baths - provide privacy - keep patient covered as much as possible - start with face-trunk-upper extremities-lower extremities-perineal area - move cleanest -> dirtiest 42. What are the nursing considerations for perineal cleaning? - wipe front to back - use a clean washcloth, clean towel, and clean water 43. How do we encourage a patient to participate in their baths? - allow them to wash their faces or perineal area if they are able to - give them all the materials and let them do what they can control 44. Name some benefits of perineal care - maintain skin integrity - relieve discomfort - prevent transmission of micro organisms (catheter care) 45. Name some patient education for foot care - inspect daily - use lukewarm water, and dry feet thoroughly - apply moisturizer - avoid over-the-counter meds with alcohol or other strong chemicals - clean socks - check shoes for objects, rough seams, or edges - cut nails straight across - avoid self-treating corns or calluses - do not apply heat 46. Sudden attacks of sleep that are often uncontrollable often happens at inappropriate times and increases the risk of injury narcolepsy 47. Patient education for Narcolepsy - exercise regularly - eat small meals that are high in protein - avoid activities that increase sleepiness (sitting too long, warm environments, drinking alcohol) - avoid activities that could cause injury to the client should they fall asleep (heights, driving) - take naps - take prescribed simulants C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing." A. "Have your working hours changed recently?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing." 54. A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime. A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake at least 2 hr before bedtime. 55. A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication. C. Allow the client to take a bath in the evening 56. A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day." B. "I'll take a short nap whenever I feel a little sleepy." 57. Name some nursing actions for immobility - turn patient every 2 hours - ROM exercises - check for sores (redness) - pad bony prominences 58. A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction C. Pressure injury 59. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr. A. Encourage the client to perform antiembolic exercises every 2 hr. 60. When you see indications of skin breakdown, what is your next action? Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints, wedge pillows) 61. What does PQRST stand for? Palliative/Provoking Quality Region/Radiation Severity Timing 62. What are some nonverbal signs of pain? - grimacing - moaning - flinching - guarding - decreased attention span - restlessness, pacing 73. Chronic pain without identifiable physical or psychological cause idiopathic pain 74. Non-Pharmacological Pain Management strategies - cognitive behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort - cutaneous stimulation: cold, heat, therapeutic touch, massage, TENS - distraction: ambulation, deep breathing, visitors, television, games, prayer, music - relaxation: yoga, meditation, progressive muscle relaxation - imagery: pleasant thought, ability to concentrate - acupuncture/acupressure - elevation of edematous extremities 75. What does Aloe promote? wound healing 76. What does chamomile promote? anti-inflammatory, calming 77. What does echinacea promote? enhances immunity 78. What does garlic promote? inhibits platelet aggregation (clumping) 79. What does ginger promote? antiemetic (prevents N/V) 80. What does ginko biloba promote? improves memory 81. What does ginseng promote? increases physical endurance 82. What does valerian promote? Promotes sleep, reduces anxiety 83. A variety of therapeutic or preventive health care practices, such as homeopathy, naturopathy, chiropractic, and herbal medicine, that do not follow generally accepted medical methods and may not have a scientific explanation for their effectiveness. used in addition to or to enhance conventional medical care complementary therapy 84. Includes herbs and other "natural" products as often found in ancient records; these products are not controlled or tested by the U.S. Food and Drug Administration and are considered to be dietary supplements; however, they are often the basis for discovery of an active ingredient that is later developed into a regulated medication treatment approaches that are used in addition to or to enhance conventional medical care alternative therapy 85. A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? A. Chamomile B. Ginseng C. Ginger D. Echinacea A. Chamomile 86. A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. Offer information on a relaxation technique and ask the client if they are interested in trying it. B. Request a social worker see the client to discuss meditation. C. Attempt to use biofeedback techniques with the client. D. Tell the client many people feel the same way before surgery and to think of something else. A. Offer information on a relaxation technique and ask the client if they are interested in trying it. 87. Complications of urinary elimination UTIs 88. UTI patient education - wipe front to back - pee before and after sex - cleanse beneath foreskin - provide catheter care regularly (nurses) 89. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? Wealth Comfort Cleanliness Achievement Youth and beauty 100. What are some Dominant Values among Hispanic or Latino? Extended family Group emphasis Fatalistic Faith and spirituality 101. What are some Dominant Values among Native Americans? Bonding to family or group Acceptance of nature (Mother Earth) Tradition Sharing Belief in a spiritual power Respect of elders 102. What are some Dominant Values among Asian and Pacific Islander? Extended family Respect for elders Group orientation Subordination to authority Conformity Self-respect and self-control Love of the land 103. What are some Dominant values among Black and African Americans? Family bonding Matrifocal Spiritual orientation Present-oriented 104. Name some enhancing nonverbal cues Direct eye contact Concerned facial expression Leaning forward Personal space Professional appearance Sitting down to talk Touch 105. Stages of Therapeutic Communication Pre-interaction Orientation Working Termination 106. Name this stage of Therapeutic Communication: - Even before you meet the client, this phase is established. - You begin establishing communication by gathering information about the client, but the nurse and client do not have direct communication. Pre-interaction phase 107. Name this stage of Therapeutic Communication: - The phase begins when you meet the client and introduce yourself and your role in the relationship. - The goal of this phase is to establish rapport and trust through the use of verbal and nonverbal communication. orientation phase 108. Name this stage of Therapeutic Communication: - The bulk of therapeutic communication occurs in this phase - During this phase, the nurse communicates caring, the patient expresses thoughts and feelings, mutual respect is maintained, and honest verbal and nonverbal expression occurs. working phase 109. Name this stage of Therapeutic Communication: - The conclusion of the relationship, whether at the end of the nurse's shift or on the client's discharge from the unit, facility, or service. - Reviewing and summarizing help to bring the relationship to a comfortable conclusion. termination phase 110. The 5 key characteristics of therapeutic communication empathy respect genuineness concreteness confrontation 111. Name ways to enhance therapeutic communication Active listening Establishing trust Being assertive Restating, clarifying, and validating messages Interpreting body language and sharing observations Exploring issues 120. What does OSHA stand for? Occupational Safety and Health Administration 121. What is OSHA's purpose? to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance. 122. A means of documenting problem events within a hospital or other medical facility incident report 123. Steps of the Nursing Process ADPIE Assessment Diagnosis Planning Intervention Evaluation 124. What happens during the Assessment phase of the Nursing Process? systematic collection, organization, validation, and documentation of patient data 125. What happens during the Diagnosis phase of the Nursing Process? The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs. 126. What happens during the Planning phase of the Nursing Process? - the nurse sets measurable and achievable short- and long-range goals for this patient. - Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. 127. What happens during the Intervention phase of the Nursing Process? - activities or actions that a nurse performs to achieve client goals. - Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. 128. What happens during the Evaluation phase of the Nursing Process? - to determine whether, after application of the nursing process, the client's condition or well-being improves. - The nurse conducts evaluation measures to determine if expected outcomes are met, not the nursing interventions. 129. Normal respiratory rate 12-20 breaths per minute 130. Normal range for BP 120/80... Systolic: 90-120 Diastolic: 60-80 131. Normal range for temperature 96.4 -99.5 degrees Fahrenheit Oral: 98.6 Tympanic: 99.6 Rectal: 99.6 Axillary: 97.6 132. Normal range for pulse/HR 60-100 beats per minute 133. Normal range for O2 Sat % 94%-100% 134. Maslow's Hierarchy of Needs Self-actualization Esteem Love/Belonging Safety Physiological 135. What parts of the nursing process cannot be delegated to an NAP (nursing assistive personnel such as LPN, CNA) Assessment Nursing diagnosis Planning Evaluation ****Interventions are the only part of the nursing process that can be delegated.