306 Test #3

Front 1

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?

Back 1

Activity intolerance related to pain

Front 2

The nurse selects a variety of teaching methods to use with clients. For a toddler, the nurse should use:

Back 2

Simple explanations and pictures

Front 3

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:

Back 3

Telling

Front 4

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?

Back 4

Timing

Front 5

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?

Back 5

Activity intolerance related to pain

Front 6

A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:

Back 6

Position the client upright

Front 7

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:

Back 7

Assist the client to obtain the necessary information to make this decision

Front 8

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:

Back 8

Denial

Front 9

Hospice nursing care has a different focus for client. The nurse is aware that client care provided through a hospice is:

Back 9

Designed to meet the client’s individual wishes, as much as possible

Front 10

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:

Back 10

Crying off and on

Front 11

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:

Back 11

Maintain consistency in the same bedtime ritual

Front 12

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:

Back 12

“Do you snore loudly or experience headaches?”

Front 13

For a client who is currently taking a diuretic, the nurse should inform the client that he or she may experience:

Back 13

Nocturia

Front 14

Which of the following information provided by the client’s bed partner is most associated with sleep apnea?

Back 14

Excessive snoring

Front 15

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:

Back 15

Finishing office work

Front 16

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:

Back 16

Injury, risk for

Front 17

With advancing age, which of the following normal physiological changes in sensory function occurs?

Back 17

Decreased sensitivity to pain

Front 18

The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:

Back 18

Use visual aids such as the hands and eyes when speaking

Front 19

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?

Back 19

Keeping the client loosely covered with sheets and blankets

Front 20

The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:

Back 20

Using a picture chart for the client’s responses

Front 21

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:

Back 21

The gray/black settings on the stove handles

Front 22

necessary loss

Back 22

have all your life, come with everyday life

Front 23

actual loss

Back 23

when you lose a person or object that can no longer be felt or known

Front 24

percieved loss

Back 24

anything defined by the cliebt

Front 25

maturational loss

Back 25

ex: child going to kindergarten or empty nest syndrome

Front 26

situational loss

Back 26

sudden or pnpredictable loss, tornado for example

Front 27

grief

Back 27

emotional response to loss

Front 28

mourning

Back 28

outward social expression of loss

Front 29

beraevement

Back 29

emotional response, inner feelings, and outward reaction of the survivor

Front 30

Kubler- Ross stages of dying

Back 30

denial
anger
bargaining
depression
acceptance

Front 31

Bowlby's theory of grief
phases of mourning

Back 31

numbing
yearning and searching
disorganization and despair
reorganization

Front 32

Worden's theory of grief
4 tasks of mourning

Back 32

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

Front 33

complicated grief

Back 33

chronic grief
delayed grief
exaggerated grief
masked grief

Front 34

nursing process- planniong

Back 34

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

Front 35

documenting pain

Back 35

location
intensity
quality
duration
variations, rythyms
causes
relief measures
effects of pain
manner of expressing pain

Front 36

assessing pain

Back 36

WILD SCARF
when does it occur
intensity
location
duration
does it affect quality of sleep
affect ability to concentrate
affect appetite or activity level?
affect relationships?
in fluence fatigue or functioning?

Front 37

3 step analgesic ladder

Back 37

0-3 mild pain
4-6 mild to moderate pain
7-10 moderate to severe pain

Front 38

mild pain

Back 38

non opioid or adjuvant

Front 39

mild to moderate pain

Back 39

opioid
non opioid
adjuvant

Front 40

moderate to severe pain

Back 40

opioid
non opioid
adjuvant