Chapters 30,31,32
Biofeedback training
What is help me with my thoughts and physiological responses to stress
An 18-month-old patient is brought into the clinic for evaluation because the parent is concerned because the child hits siblings and says only “No” when communicating verbally. Which recommendation by the nurse will be best for this situation?
What is Assure the mother that the child is developing mentally within specified norms.
Patient in Hospice, very close to dying, what do you see?
What is Cheyne-Stokes breathing
The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse’s action?
What is Reduced kidney functioning
A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, “Ow, that was sharp!” What conclusion about the child will the nurse come to when interpreting the child’s response?
What is Perception is intact.
The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill?
Interpretation
During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing?
What is Receptivity
What nurses document about their Hospice patient that has died.
What is time of death, special preparations, location of ID tags, and time of body transfer
A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition would the nurse suspect?
What is Urge incontinence
A nurse is assessing a patient who began experiencing severe pain 1 day ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is a sharp pain in my back.” Which type of pain does the nurse document the patient is having at this time?
What is Superficial pain
A nurse is assessing an 18-month-old toddler. The nurse distinguishes normal from abnormal findings by remembering Gesell’s theory of development. Which information will the nurse consider?
The cephalocaudal pattern describes the sequence in which growth is fastest at the top.
The maternity nurse is providing instructions to a new parent regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the parent to take which measure?
What is allow the newborn infant to signal a need.
A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage?
1. Resistance
2. Exhaustion
3. Alarm
What is 3, 1, 2
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
What is Partial-thickness skin loss of the dermis
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
What is Difficulty hearing high pitch
The hormones that are affected with a patient that just had a motor vehicle accident and likely cause of abnormal VS?
What are epinephrine and norepinephrine?
The nurse is observing a 2-year-old hospitalized patient in the playroom. Which activity will the nurse most likely observe?
What is sitting beside another child while playing with blocks
A veteran is hospitalized after bilateral amputee of the lower part of both legs, injuries sustained during military service - the loss that the nurse will focus plan of care?
What is situational loss?
The nurse is caring for a patient who is having difficulty expressing simple ideas in words. Which type of aphasia will the nurse report to the oncoming shift?
Expressive
A patient is experiencing insomnia. Which statement by the patient will indicate to the nurse that outcomes are being met?
What is “I go to sleep within 30 minutes of lying down.”
The nurse is caring for a 4-year-old child who is non-verbal demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child?
What is use the FLACC scale
A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take?
What is review the patient’s list of medications at each visit
The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?
What is a decrease
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?Infant with temperature of 102.2°F and diarrhea for 3 days
teenager with a sprained ankle
middle-aged adult with abdominal pain
older adult with nausea and vomiting
What is an infant with temperature of 102.2°F and diarrhea for 3 days
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority?
What is Ask the patient to rate and describe the pain