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40 Cards in this Set

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A nurse is teaching a group of older adults techniques to promote medication safety. Which statement made by the older adult indicates the teaching is ineffective?
"My daughter knows the reason why I take each of my medications and I think that's okay."
The family of a 78-year old patient complains to the nurse that the patient is up and wandering around the house all hours of the night and is disturbing everyone's sleep. Which response should the nurse use initially?
"What does he do during the day?"
Based on the goals of Healthy People 2010, a nurse focuses on the health screening for which group?
Young African Americans are screened for HTN.
Which part of a functional assessment can be assigned to an unlicensed assistive personnel?
vital signs
Which statement best teaches an older adult about safety issues related to driving?
Turn the head to side to side to compensate for peripheral vision.
A nurse is screening healthy adolescents for health risks. Which factor should be included in this screening?
suicide
a 49-year old divorced female is in the clinic for a routine PE. Which statement indicates the need for further screening during the examination?
"I do not use protection since I have gone through menopause."
An 89-year old patient states, "I live alone and I have little money. On sunny days, I don't use my AC. I don't like to get a flu shot." What nursing Dx would be priority when using Maslow's hierarchy of needs?
ineffective thermoregulation
An 80-year old patient has a neuromuscular impairment with very little fine motor improvement. Which nursing Dx is priority for this patient?
self-care deficit: dressing
Which activity should a nurse suggest to a mother of a 2-1/2 year-old child?
jumping using both feet
Which instructions would a nurse provide to a mother to instruct how to do a cooling sponge bath for her 5-year daughter whom has a fever of 102?
"Discontinue the sponge bath if the child shivers during the bath."
A patient expresses interest in mind-body therapies to increase the release of insulin from the pancreas to improve his diabetes. Which therapy would the nurse recommend?
yoga
For which patient would a back massage as a comfort measure be most appropriate?
patient who is experience sleeping difficulty
An adult patient reports not sleeping well at night. Which instruction should the nurse provide the patient to promote restful sleep?
Limit alcohol intake in the evening.
A patient is experiencing a pulsating sensation in relation to a noxious stimulus. Which nursing Dx is appropriate for this patient?
impaired comfort
Which self-healing methods should nurses use to foster their own health and well-being?
Challenge the belief that others always come first.
Which instructions should the nurse include in the teaching plan of a patient with diabetes who asks about the application of an ice pack for chronic knee discomfort?
"You are at risk for not being able to feel the temperature of a cold pack, which could cause tissue damage."
Which nursing action would create a healing environment that would best facilitate feelings of self-worth in patients in a LTC facility?
teachin patients about making health care decisions
Which nursing action best promotes warmth and sleep for an older adult patient?
Use flannel sheets on the bed.
A CNA is giving hygiene care to an older African American who has impaired comfort related to itching skin, The CNA asks what can be done to help this patient. What is the nurse's most appropriate response?
Apply a lanolin-based lotion.
The nurse is caring for a patient who is receiving an NSAID. The nurse should give priority to which nursing Dx?
risk for injury related to GI irritation
A patient is receiving MSO4 via PCA pump. The patient states, "I've been pushing the button and I still have pain." The nurse should take which initial action?
Check to ensure that the pump is properly programmed.
The nurse assesses a patient who reports experiencing intermittent pain for the past two months. Which clinical Euphoria manifestation will be present?
decreased appetite
The nurse teaches the family of a patient who is being cared for at home how to manage the patient's pain. Which finding would best indicate that the nurse's teaching was sucessful?
The patient indicates satisfaction with pain control options.
The nurse is planning home care for a patient with chronic pain related to degeneration of the vertebrae. Which assessment is a priority?
how the pain affects self-care abilities
How does a TENS unit relieve pain?
blocks small nerve fibers by stimulating large ones
Which assessment of a 4-year old with severe abdominal pain will provide objective info as to the exact location of the pain?
Have the patient point to where the pain is felt.
A patient is receiving a narcotic analgesic via an epidural catheter. Which clinical manifestation indicates a possible side effect of this therapy?
urinary retention
Using a back rub to reduce pain intensity is based on which theory?
gate control
Which statement reflects an unbiased understanding of pain?
Euphoria is an expected side effect of proper analgesic control.
A patient with chronic illness has developed complications. Which factor is important for the nurse to assess?
the patient's efforts to manage the chronic illness
Which nursing action is a priority when caring for a patient with a chronic disease?
provide supportive assistance for management of care
Which data supports the nursing Dx of altered growth and development related to chronic illness?
The parent plans the daily activity schedule of a 13-year old.
A patient with chronic illness says to the nurse, "You know I'm not sick now, I feel better each day." How should the nurse interpret the patient's statement? Patients who respond this way
see themselves as sick when the illness interferes with their daily functioning
Which nursing action assures that a caregiver safely administers medications through a PEG tube?
Flush tube with clear water between administrations of medications.
Which clinical manifestation in a patient with CF causes the greatest disruption in the adolescent's ability to successfully attain Erikson's stage of identity vs. role confusion?
chronic cough
The nurse provides care for a patient who has just been placed in an extended care facility. The pt is A&O and able to do limited self-care. Which pt attribute would be most likely to contribute positively to the pt's adaption to loss of independence?
an active and strong spirituality
Which statement by a pt regarding advanced directives indicates that the pt understands their use?
"If I have a stroke, I do not want CPR or a ventilator, so I signed an advanced directive."
During a home visit, the nurse notices that the pt is lying in a urine-soaked bed and areas of inflammation appear on the pt's buttocks and elbows. The caregiver appears tired and states that they are doing their best for the pt, but they are just overwhelmed. What would be the appropriate intervention?
Suggest respite care for the pt.
Which statement made by the pt on long-term anti-coag therapy indicates that the nurse needs to provide the pt with extra info?
"I use laxatives as needed to keep my stools soft."