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40 Cards in this Set

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  • Back
The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
Activity intolerance related to pain
The nurse selects a variety of teaching methods to use with clients. For a toddler, the nurse should use:
Simple explanations and pictures
The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is:
The nurse is demonstrating to the client how to put on anti-embolytic stockings. In the middle of the lesson, the client asks, “Why have my feet been swelling?” The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should adhere to?
The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
Activity intolerance related to pain
A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:
Position the client upright
The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. The nurse should:
Assist the client to obtain the necessary information to make this decision
A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, “I wonder why this happened to me?” According to Kübler-Ross, the nurse identifies that this stage is associated with:
Hospice nursing care has a different focus for client. The nurse is aware that client care provided through a hospice is:
Designed to meet the client’s individual wishes, as much as possible
The nurse is using Bowlby’s phases of mourning as a framework for assessing the client’s response to the traumatic loss of her leg. During the “yearning and searching” phase, the nurse anticipates that the client may respond by:
Crying off and on
The mother of a 2-year-old tells the nurse that the child has started crying and resisting going to sleep at the scheduled bedtime. The nurse should advise the parent to:
Maintain consistency in the same bedtime ritual
The nurse is completing an assessment on the client’s sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is:
“Do you snore loudly or experience headaches?”
For a client who is currently taking a diuretic, the nurse should inform the client that he or she may experience:
Which of the following information provided by the client’s bed partner is most associated with sleep apnea?
Excessive snoring
The nurse is discussing sleep habits with the client in the sleep-assessment clinic. Of the following activities performed before sleeping, the nurse is alert to the one that may be interfering with the client’s sleep, which is:
Finishing office work
The nurse has completed the admission assessment for a client admitted to the hospital’s subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is:
Injury, risk for
With advancing age, which of the following normal physiological changes in sensory function occurs?
Decreased sensitivity to pain
The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:
Use visual aids such as the hands and eyes when speaking
The client has hyperesthesia apparently associated with a neurologic trauma. Which of the following is an appropriate nursing intervention in regard to the client’s sense of touch?
Keeping the client loosely covered with sheets and blankets
The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:
Using a picture chart for the client’s responses
The nurse completes a safety assessment during a home visit to an older adult client. Of the following observations made by the nurse, the one that is of greatest concern for this client who has evidence of sensory impairment is:
The gray/black settings on the stove handles
necessary loss
have all your life, come with everyday life
actual loss
when you lose a person or object that can no longer be felt or known
percieved loss
anything defined by the cliebt
maturational loss
ex: child going to kindergarten or empty nest syndrome
situational loss
sudden or pnpredictable loss, tornado for example
emotional response to loss
outward social expression of loss
emotional response, inner feelings, and outward reaction of the survivor
Kubler- Ross stages of dying
Bowlby's theory of grief
phases of mourning
yearning and searching
disorganization and despair
Worden's theory of grief
4 tasks of mourning
accept reality of loss

walk through pain of grief

adjust to environment in which deceased is missing

emotionally relocate deceased and move on with life
complicated grief
chronic grief
delayed grief
exaggerated grief
masked grief
nursing process- planniong
select commuinication strategies that assist client in accepting the loss

select intervention design to maintain dignity and self esteem

provide skills and knowledge for family to manage and care for the dying
documenting pain
variations, rythyms
relief measures
effects of pain
manner of expressing pain
assessing pain
when does it occur
does it affect quality of sleep
affect ability to concentrate
affect appetite or activity level?
affect relationships?
in fluence fatigue or functioning?
3 step analgesic ladder
0-3 mild pain
4-6 mild to moderate pain
7-10 moderate to severe pain
mild pain
non opioid or adjuvant
mild to moderate pain
non opioid
moderate to severe pain
non opioid