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120 Cards in this Set
- Front
- Back
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A pt uses the arms of friends to walk,
sits all morning and has an unsteady gait. The pt states "I could walk until I got the flu a month ago". What nrsg action is appropriate? |
Refer pt to physical therapy. Acute illness (flu) can cause chronic problems (mobility)
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What is an important instruction for a nurse to give to parents of a toddler re: home safety?
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Place hot pots on the back burner
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Where should poisons, cleaning solutions, medications be kept in a house with a toddler?
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In a locked location
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Important safety info for a school age child includes
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Bicycle safety, wearing a helmet
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How often should middle ages pts get eye exams?
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every 2 years
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How often shoulder middle aged pts get physicals?
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yearly
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Men should have a testicular exam
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yearly
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Which information during an assessment of a healthy 80 y/o pt is normal?
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Decreased taste (r/t atrophy of taste buds and decrease in sense of smell)
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Frequent diarrhea is not normal
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at any age
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Blood pressure tends to do what w/aging?
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Increase
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Older adult males have difficult with decrease in
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frequency of erections
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Pelvic muscle exercises should be done how often?
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A few times a day
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How much water should a person drink per day?
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at least 8 glasses unless contraindicated
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Artificial sweetners can irritate
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the bladder
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Older adults have decreased thirst, an appropriate nursing intervention would be to
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encourage the pt to drink fluids even when they are not thirsty
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A pt states "On sunny days, I don't use my AC to save $". An appropriate nrsg dx for this pt is
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ineffective thermoregulation
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A health risk screen on a young adult should include
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eating disorders
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A health risk screen on a school aged child should include
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dental caries
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A health risk screen on a preschooler should include
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vision changes
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A motor skill appropriate for a 6 m/o baby is
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sitting without support
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An 18 m/o baby should have enough motor skill to
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pick up tiny objects
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The first stage in gross motor development in a baby is
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head control
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What is an appropriate behavior for a 3 y/o child?
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Feeding self completely
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A five year old should be able to
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follow a simple 3 step command, tie shoelaces in a bow and stand on alternating feet
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Administering an IM injection to a sleeping child may
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increase trauma to the pt and cause the child to be afraid to fall asleep
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A patient is attached to numerous physiological monitors, appears frightened and states "i've had enough." this pt is probably in
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sensory overload
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Sensory overload is a result of
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increased demands on the pt's attention
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The nurse suggest to a pt to use all senses to create a mentally safe environment. The nurse is suggesting
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guided imagery
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Biofeedback
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requires instrumentation and provides prompt feedback on the pt's BP, brain waves and other body functions
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Progressive relaxation is
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combining deep relaxation of muscles and a specific method of breathing in a sequential manner.
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According to the psychodynamic theory, a patient who places high value on control is most likely to have which response when control is threatened?
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Anxiety is the initial stress reaction
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According to the psychodynamic theory, a pt with stress who is predisposed to depression is
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more likely to have depression than anxiety
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Hostility is an escalation from
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anxiety
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Using a K pad will cause the pt who c/o being cold
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to remain cold, and also have blood pooling in one area
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A frail elderly pt may benefit from what to improve comfort?
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Soothing, therapeutic touch
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Empathy requires
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the nurse to understand the pt's feelings and thoughts while reminaing objective
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The nurse should convey an attitude of caring and attention while still
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listening to the pt's thoughts and feelings
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What is the best approach for the nurse to use in assessing a pt for cultural comfort measures that may facilitate pharmacological interventions?
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Asking the pt about any rituals that may increase their comfort
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A fresh post op pt should be given pain medication
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around the clock, it is better to offer it at regular intervals than wait for the pt to ask for it
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An intevention to help an immobile pt mobilize secrtions is
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turning the pt from side to side every 2 hrs
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A pain relief method for a woman in labor using the gate control theory includes
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a message and back rub
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An appropriate goal for a pt who has chronic pain is
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reporting a good night's sleep, pain can interfere w/sleep and lack of sleep can increase perception of pain
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An unrealistic goal for a patient with chronic pain
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is reporting the pain is no longer present
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A benefit of adding a NSAID to an opioid regimen is
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less need for opioid
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The most important side effect of Morphine sulfate for the nurse to report is
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Shallow respirations
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Duration describes
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The length of time a pt has pain
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The pain threshold is
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the amount of painful stimuli that causes the pt to have pain
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Chemicals manufactured by the body that act to decrease pain by blocking the transmission of the pain impulses are
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Endorphins
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A pt wearing a TENS unit may experience a
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vibrating or tingling sensation where the electrodes are placed
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A pt who speaks slowly and in monotone should be assessed to
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see if the pt's affect is r/t pain
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Which stage can nurses begin to use the FACES scale to assess pain?
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Ages 3-5 yrs
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Gastrostomy feedings should be allowed to flow by
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gravity
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The feeding syringe for a pt with a gastrostomy should be
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No higher than 18 inches from the abdominal wall
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An adolescent with which chronic disease will have the hardest time with coping?
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Scoliosis, r/t alterted physical appearance and treatment usually requires a brace
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What is a common reason for noncompliance in pts with HTN??
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HTN is often a silent (asymptomatic disease). Pts feels that if they dont feel sick, they are better and do not need meds
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A middle aged pt has a chronic illness. The # of necessary lifestyle changes will be influenced most by
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the degree of disability,
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A priority intervention for a pt with chronic illness is
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assisting the pt to find safe activity levels
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An older adult has a complex med regimen. To determine if this pt can follow the regimen, A priority assessment by the nurse would be
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assessing pt's cognitive status
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The nurse is caring for a pt w/acne that has disturbed body image. Appropriate intervention would include
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therapeutic touch and eye contact
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Symptoms of chronic illness are
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unpredictable
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Which loss most strongly impacts a pts sense of self?
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Altered body image from severe surgical scarring
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What is a common characteristic for death in all cultures? (this is a ****** question, I think!)
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Death is considered a passage into the next phase in life.
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Death does not always result in
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greiving
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A pt's parents have just both died. The pt states "I feel no loss or pain". The pt is using what defense mechanism?
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Repression---this pt is banishing a memory
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What is the relationship between greif and mourning?
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Mourning allows the expression of grief
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Mourning refers to
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the ceremonies that allow people to express their grievances
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Grief is an
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emotion
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What is a nursing diagnosis for a pt on hospice care?
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Anticipatory grieving
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Hospice care is for pts with how long left to live?
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6 mo or less
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A pt requests medical staff do nothing to prolong his life. This is an example of
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passive euthanasia (allowing a person to die naturally)
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When a person actively takes the steps to help another person end their life, it is refferred to as
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active euthanasia
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Providing the means to a person to end their life is called
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assisted suicide
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The first concern of the nurse who is caring for a dying child is
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controling the child's pain
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A healthy self esteem will provide
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the structure for a patient to resolve issues such as grief
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What was inspired by the hospice movement?
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The need for palliative care
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Which religion does not permit organ donation?
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Jehovah's witness
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Which religion does not permit cremation?
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Mormon (church of Latter Day Saints)
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Buddhists consider organ donation
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an act of mercy
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There is an increased sensitivty to light
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as death approaches
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THe last sense lost in a dying pt is
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hearing
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A dying pt with noisy secretions may be given which meds?
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Scopalomine, Atropine or Morphine
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A pt is told they have only 3 months to live. The pt says they do not believe their life was meant to be over yet and they wont die so soon. This pt is in what stage of grief?
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Bargaining. During bargaining the pt develops hope that death is going to be postponed
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Depression occurs when the pt accepts what?
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Certainty of death. This depression will come before full acceptance
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What is the difference between hospitals and hospice?
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Hospitals focus on curing the illness and extending life. Hospice focuses on keeping the dying pt from suffering and end of life free from pain, anxiety and depression.
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What is the rationale for a terminally ill pt to enter a hospice program?
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To allow the pt to die with dignity and in peace
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A palliative care nurse is caring for a terminally ill single mother with children. What is the most important step to take to ensure the pt's wishes will be followed?
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Discuss the need for advanced directives such as power of attorney
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A dying pt remarks "cancer made me closer to God". This pt is experiencing
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transcendence, the recognition of something greater than oneself
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A nurse is planning care for a pt dx with cancer. This pt has one to two years to live, which would disqualify them from receiving
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hospice care
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What is the best action for a school teacher who is working w/ a hearing impaired child?
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Seat the child in the center of a semi-circle to promote participation by the child, lip reading and awareness of visual cues and classroom activity
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What is an important intervention for the nurse who is caring for an elderly pt with a hearing aid?
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Assess the pt's external auditory canal for pressure ulcer
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A nurse is caring for a swimmer w/recurrent otitis externa, the nurse recommends
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the pt wears earplugs while swimming
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What is the expected action of giving a miotic to a pt w/glaucoma?
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to constrict the pupils and pull the ciliary muscles, increasing the outflow of aqueous humor
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What is the criteria for declaring a patient legally blind?
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The corrected vision in the pt's better eye is 20/200 or worse
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Which nursing action increases the independence of a pt with left henomynous hemianopia?
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Placing the pt's important items on the right side of the bedside table
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Which intervention should the nurse include for a pt with advanced glaucoma?
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Place objects directly in front of the pt, as pts with glaucoma have decrease in peripheral vision
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When demonstrating asepsis in administering eye ointment, the nurse
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washes the eye from inner to outer canthus, wipes the first bead from the dropper and discards it before placing the ointment and does not touch the eye with the applicator
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What part of the brain is the sensory center?
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Thalamus
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Gradual blurring vision is common in pts developing
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cataracts
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Pilocarpine is
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a miotic used to constrict the pupil and increase aqueous outflow in the tx of glaucoma
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Beta Blockers like Timolol (timoptic) decrease
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the production of aqueous humor
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Cold compresses may alleviate the sx of
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conjunctivitis
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What is the best toy for a 5 y/o blind child?
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A ball w/a bell inside
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Furosemide (Lasix) can cause
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ototoxicity and hearing loss
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Norpace can cause
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blurred vision and narrow angle glaucoma
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Dilantin can cause
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blurred or double vision
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After middle ear surgery the pt should avoid bending, straining and lifting for how long?
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2-3 weeks
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Popping and crackling in the operative ear of a pt who just had middle ear surgery is
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normal for 3-5 wks
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A pt w/an eye patch on should not
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drive
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A pt with a foreign object in the eyes should have a
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patch or cup placed over the eye to protect it until the MD can assess-never anything putting pressure on it
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Sickle cell anemia is a disease primarily found in
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African Amer. pts
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A pt requests a kosher diet. The nurse should
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clarify the meaning of kosher w/the pt first before placing request
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What is a priority screening for Native Amer. pts?
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Diabetes
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What immunization info is important for a nurse the collect from a pt born before 1956?
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Titers for MMR
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What is important for the nurse to emphasize older adults to get?
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Flu and PNA vaccine
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What is morbidity?
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The incidence of a specific illness in the population at a specific time
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What is mortality?
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The death rate from specific illness or population
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What is infant mortality?
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Rates the # of deaths per 1000 live births
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What is the most important criteria for determining whether the pt can have home care vs SNF/Rehab?
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If the condition is predictable or not. A predicatable condition is good for home care
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What is the first step in designing any educational program?
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Assessing learning needs of population
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If a community health nurse notes the pt and family are non compliant w/tx plan, what should the nurse do?
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Reassess the sitution, reeducate and revise care plan
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