A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required?
"I can expect my newborn to sleep an averag
b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent
A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action?
No action is necessary as this is a normal finding during sleep.
Call the primary care provider to report possible neurologic deficit.
Lower the temp
a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.
A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply.
He is aware of his surroundings at this po
c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep
A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply.
REM sleep constitutes much of the sleep cycle of a preschool child.
By the age of 8 year
d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older ad
A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include?
Drinking a cup of regular tea at night induces sleep.
Using alcohol moderately promotes a deep sleep.
Having a small bedtime s
c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity wit
A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply.
A patient who has uncontrolled hypothyroidism.
A patient with coronar
a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who
A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply.
A patient who is taking iron supplements for anemia.
A patient with Parkinson's
b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional
A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to p
c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of P
A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder?
Circadian rhythm sleep-wake disorder
Narcole
b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by a
A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply.
Daily mental activities
Daily physical activities
Morning and evening body temperature
Daily measur
a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure
To promote sleep in a patient, a nurse suggests what intervention?
Follow the usual bedtime routine if possible.
Drink two or three glasses of water at bedtime.
Have a large snack at bedtime.
Take a sedative-hypnotic every night at bedtime.
a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small prote
A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select a
a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and ad
A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient?
The use of a central nervous system
c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central
A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep?
Keep the room light dimmed during the day.
Keep the room cool.
Keep the door of the room open.
Offer a sleep aid medication to patients on a
b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should o
A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients?
Increase physical activities during the day.
Encourage short periods of napping d
a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5?6? and his current weight is 325 lb. What would the nurse document as his BMI?
50.5
52.4
54.5
55.2
b
A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply.
Absence of nausea, vomiting
Weight gain
Bowel sounds with
a, c, e. Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within n
A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process?
Stroke the underside of the patient's chin to promote swallowing.
Serve meals in different places and at different times.
O
a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide
A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient?
Administering pain medication after meals.
Encouraging food from home when possible.
Scheduling his respiratory therapy before eac
b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?
Feed the patient solids first and then liquids last.
Place the head of the bed at a 30-degree angle during feeding.
Puree all
d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of th
A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply.
A patient with irritable bowel syndrome who has intractable diar
a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is ex
A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
Remove the tray from the room.
Administer an antiemetic and encour
a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small
A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?
Vitamin B malnutrition
Obesity
Dehydration
Vitamin C d
a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, bu
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly?
The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site.
The nurse we
a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tub
A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patien
d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placem
d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the
Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18?
Risk for Imbalanced Nutrition: More Than Body Requirements
Imbalanced Nutrition: More Than Body Requirements
Readiness for Enhanced Nutrition
Imbalanced Nu
d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and c
A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm?
Malabsorption
Anemia
Protein depletion
b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorpt
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment?
Use warm water or air and
a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. T
A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?
A 19-year-old patient who is a vegan
An older adult patient who takes daily
c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan sh
A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this p
a, c, d, f. In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar,
A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling.
c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.
5% dextrose in 0.9% NaCl
0.9% NaCl (normal saline)
Lactated Ringer's solution
0.33% NaCl (?-strength n
d, e. 0.33% NaCl (?-strength normal saline), and 0.45% NaCl (?-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?
Recording intake and output.
Testing skin turgor.
Reviewing the complete
d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessa
Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3?, 14 mEq/L?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased P
A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement?
Explaining the mechanisms involved in transporting fluids to and from intracellular compartments.
Keeping fluids readily available fo
b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation?
Remove the IV from the site and start at another loc
a. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be noti
A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these sy
a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report sy
A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the:
Kidneys
Lungs
Adrenal glands
Blood vessels
b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid h
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Encourage foods and fluids with high sodium content.
Administer oral K supplements as ordered.
Caution the patient about e
b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient abou
A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.
Place your answer on the line provided below.
Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:
A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would
d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the
When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document?
1
2
3
4
b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?
Slow or stop
a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (
A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?
A pinched and drawn facial expression
Deep, rapid respirations.
Moist crackles heard upon auscultation
Tachycardia
c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing r
A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure
a, b, c. The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psych
A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply.
The family arranges for a funeral for their loved one.
a, b, f. Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of li
A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy l
c. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends ove
A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying?
a. The patient's statement reflects the acceptance stage of death and dying defined by K�bler-Ross.
A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the
b. This response by the nurse validates that what the patient is saying has been heard and invites him to share more of his feelings, concerns, and fears. The other responses either deny the patient's feelings or change the subject.
A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate?
"Oh, don't worry abou
b. Using an open-ended question allows the patient to continue talking. An open-ended question, such as, "What seems to be concerning you the most?" provides a means of encouraging communication. False reassurances are not helpful. Also, the patient's fee
A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare?
POLST form
Durable power of attorney for health care
Living will
Allow Natural Death (AN
b. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in pa
A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherenc
a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Yet, n
A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear abo
.
a. The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order. The wife would want all aggressive treatment to be stopped at this point, and all care to be directed to a comfortable, dignified death. A
A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply.
Participate in the decision-making process by offering the family information about the advantages and disadva
a, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supp
A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and dec
c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided. The other diagnoses do not fit the assessment data.
A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care?
To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient.
The nurse sits on the
b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body, and many patients retain a sense of hearing alm
A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy?
The nurse leaves the patient in a sitting position while the family visi
a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.
The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate?
Inform the family that th
d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.
.
A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing
a. Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilit
A nurse is assessing a patient in a long-term care facility. The nurse notes that the patient is at risk for sensory deprivation due to limited activity related to severe rheumatoid arthritis. Which interventions would the nurse recommend based on this fi
b, d, e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for
A nurse is assessing an older adult patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply.
The nurse asks the patient if he is bored, and if so, why.
The nurse asks the patient i
c, e, f. To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation. Asking if anything interferes with
A nurse is assessing a patient for tactile disturbances. Which question asked by the nurse would be appropriate for this assessment?
"Have you been experiencing any strange tastes lately?"
"Have you smelled odors lately that other cannot smell?"
"Can you
c. When the nurse asks: "Can you tell me what I am placing in your hand right now?" the nurse is assessing for tactile disturbances. When the nurse asks: "Have you been experiencing any strange tastes lately?" the nurse is assessing for gustatory disturba
A nurse observes that a patient who has cataracts is sitting closer to the television than usual. Which alteration would the nurse suspect is causing this patient behavior?
Altered stimulation
Altered sensory reception
Altered nerve impulse conduction
Alt
b. Cataracts are interfering with the patient's ability to receive visual stimuli, causing altered sensory reception. The nature of incoming stimuli (e.g., environmental stimuli), the conduction of nerve impulses, and the translation of incoming impulses
Which action would be most important for a nurse to include in the care plan for a patient diagnosed with presbycusis?
Obtaining large-print written material
Speaking distinctly, using lower frequencies
Decreasing tactile stimulation
Initiating a safety p
b. Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. Obtaining large-print written material is appropriate for visual alterations. Decreasing tactile stimulation is appropriate
A patient is in the late stages of AIDS, with alterations to the brain as well as other major organ systems. The patient complains of loneliness because of friends being "afraid to visit." Based on this data, what would the nurse determine to be the least
d. Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for the patient's condition. This patient is receiving decreased environmental stimuli (e.g., from lack
Which patient would a nurse assess as being at greatest risk for sensory deprivation?
An older adult confined to bed at home after a stroke
An adolescent in an oncology unit working on homework supplied by friends
A woman in labor
A toddler in a playroom
a. The patient confined to bed rest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate.
A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 1800, 1900, and 2000. A heart monitor beeps for a patient on one side, and ano
d. This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses.
A patient's spinal cord was severed, causing paralysis from the waist down. When obtaining data about this patient, which component of the sensory experience would be a priority for the nurse to assess?
Transmission of tactile stimuli
Adequate stimulation
a. Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of less importance at this time.
A nurse is diagnosing an 11-year-old student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snel
b. An important role for an 11 year old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may also represent accurate diagnoses for this patient, t
A nurse is caring for a man with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would best prevent sensory alterations for this patient?
Turn the radio or television volume up very loud and close the do
b. An important role for an 11 year old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may also represent accurate diagnoses for this patient, t
In a group home in which most patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns?
Maintaining safety and preventing sensory deterioration
a. Safety is a basic physiologic need that must be met before higher-level needs�such as love and belonging, self-esteem, and self-actualization�can be met.
A nurse assessing an 8-month-old infant suspects the infant is experiencing sensory deprivation related to inadequate parenting. Since this assessment, both parents have attended parenting classes. However, both parents work while the infant stays with a
c. Although the data show that the parents have been motivated to improve their parenting skills, it is clear from the data that the infant's sensory deprivation is still severe. The data suggest that the grandmother is not improving the infant's care, bu
An older adult in a long-term care facility walked out the door unobserved and was lost for several hours. Upon assessment, the nurse notes that the patient is confused and documents: chronic sensory deprivation related to the effects of aging. Which inte
c, d, f. Even if well motivated, ignoring a patient's confusion to prevent embarrassment may be dangerous, as it was in this case in which the appropriate safety precautions were never implemented. Reducing the type of stimuli in the room and decreasing e
An older patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient?
Assist the patient to ambulate by walking slightly behind her and grasping the arm.
Concentrate on the patien
d. When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when he or she is leaving the room. When assisting with ambulation, the nurse should walk slightly ahead of (rather than behind) the patient
A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient?
Give the p
c. When caring for a patient who is in spiritual distress, the nurse should listen to the patient first and then ask whether the patient would like to visit with a spiritual adviser. To arrange for a spiritual adviser first may not respect the wishes of t
A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly t
c. The data point to an unmet spiritual need to experience love and belonging, given the nurse's estrangement from her family and God after leaving the church. The other options may represent other needs this nurse has, but the data provided do not suppor
A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs?
Can you describe your usual spiritual practices and how you maintain them daily?
A
c. Questioning how the staff can meet patients' spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices assesses spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at p
A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat
d. On the basis of his name alone, the nurse jumped to the premature and false conclusion that this patient would want a kosher diet.
A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery?
A patient of the Adventist faith
A
c. Patients who practice the Jehovah's Witness faith believe blood transfusions violate God's laws and do not allow them. The other religious groups do not restrict modern lifesaving treatment for their members.
The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed?
Baptism frequently postpones or prevents death or suffering.
It is
d. Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family's sorrow and suffering, which is an appropriate nursing concern. Whether baptism postpones or prevents death and suffering is a religious belie
A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply.
The nurse dietitian asks a Buddhist if he has any diet restrictio
a, b, d, f. The nurse dietitian should ask a Buddhist if he has any diet restrictions related to the observance of holy days. Since Catholic Scientists avoid the use of pain medications, the nurse should ask a Christian Scientist who is in traction if she
A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality?
The child's church or religious organization
What parents say about
c. Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family's spiritual advisor, and the child's
Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation?
Patients usually want to conceal infor
d. Illness may increase spiritual concerns, which many patients find difficult to express. The other options do not correspond to actual experience.
A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients?
Calling the patient's own spiritual adviser first
Asking whether the patient has a spirit
b. Even when a nurse feels comfortable discussing spiritual concerns, the nurse should always check first with patients to determine whether they have a spiritual adviser they would like to consult. Calling the patient's own spiritual adviser may be prema
A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing?
Spiritual Alienation
Spiritual
a. Spiritual Alienation occurs when there is a "separation from the faith community." Spiritual Despair occurs when the patient is feeling that no one (not even God) cares. Spiritual Anxiety is manifested by a challenged belief and value system, and Spiri
A patient states she feels so isolated from her family and church, and even from God, "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual dist
d. Each of the four options represents an appropriate spiritual goal, but identifying spiritual supports available to this patient in the medical center demonstrates a goal to decrease her sense of isolation.
A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. Wha
c. The nursing intervention of exploring with the patient what, in addition to his family, has given his life meaning and purpose in the past is more likely to correct the etiology of his problem, Spiritual Pain, than any of the other nursing intervention
After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest abo
a. Because this patient's nursing diagnosis is Spiritual Distress: Guilt, an evaluative statement that demonstrates diminished guilt is necessary. Only answer a directly deals with guilt.
Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist
c. Helping Mr. Brown identify how his unforgiving feelings may be harmful to him is the only nursing intervention that directly addresses his unmet spiritual need concerning forgiveness. Assuring Mr. Brown that many parents would feel the same way or that