Vocabulary r/t vs
What does afebrile mean?
Your patient temperature is 97.6 what would you give them?
Afebrile means absence of fever.
You would give your patient nothing regarding a fever he/she does not have one.
ring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by:
a. using heavy pressure on the cold pack for greater effectiveness.
b. preparing to apply heat instead if cold is not effective.
c. leaving the pack in place for over 30 minutes at a time.
d. placing a towel between the pack and the skin.
d. placing a towel between the pack and the skin.
A protective towel or pad should be placed between the pack and the skin to avoid cold injury.
Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:
a. paper tape.
b. Montgomery straps.
c. Karaya paste.
d. elastic adhesive tape.
B
Montgomery straps allow the dressing to be changed without constantly applying and removing tape.
The nurse attempts to help an 86-year-old patient describe his pain because the nurse is aware the older adult may not express pain because they: (Select all that apply.)
a. are unaware of their discomfort.
b. believe pain is a natural consequence to aging.
c. are reluctant to bother the nursing staff.
d. have been culturally trained not to complain.
e. tear taking pain medication.
BCD
Older adults often do not verbalize their pain out of the mistaken belief that pain is part of aging. They are reluctant to “bother” the staff and have been culturally trained not to complain.
ravelers can combat “jet lag” by exposure to _______ for several hours.
sunlight
Exposure to sunlight for several hours will help “reset” a traveler’s internal clock and reduce the effects of jet lag.
Your patient has a temp of 101.4 what drug class of drugs would you give them to help treat this?
Antipyretics
Are drug that reduce fever
The most helpful intervention by the nurse for a hospitalized child who is having difficulty falling asleep would be to:
a. keep a night light on in the room.
b. turn off all the lights in the room.
c. have the parents bring a favorite blanket or pillow from home.
d. give of juice and cookies before being put to bed.
C
Many patients sleep better when they can have a favorite blanket or pillow from home.
The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:
a. scapula.
b. sacrum.
c. heel.
d. femoral head.
C
Debridement is not recommended for treatment of a pressure ulcer on the heel because of the small amount of tissue available at that site.
The nurse performing a focused assessment on pain will assess: (Select all that apply.)
a. history of pain.
b. verbal indicators.
c. psychological factors.
d. culture.
e. contributing factors.
ABCE
Factors to be assessed in a focused assessment of pain are the history, verbal and nonverbal indicators, psychological and other contributing factors, medication, and treatments used. Although culture may limit a person’s ability to express pain, it is not an important issue on a focused assessment.
The technique in which the practitioner alters body energy fields by passing his or her hands over the patient to determine where tensions exist is the practice of _________.
therapeutic touch
The concept of therapeutic touch involves the caregiver causing an alteration of the patient’s body energy field by passing his or her hands over the patient’s body.
5th intercoastal space midclavicular on the left side of the chest just below the nipple.
It's the only pulse you can't feel. You would give her a stethoscope to listen to her heart.
When the patient asked the nurse about the use of acupuncture for the control of back pain, the nurse warned that acupuncture can put the patient at risk for:
a. meningitis.
b. streptococcal infection.
c. hepatitis.
d. Shigella.
C
The main concern of acupuncture therapy is the use of needles for this treatment. If sterile needles are not used, there is a high risk of HIV or hepatitis transmission.
The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat:
a. low oxygen saturation.
b. atelectasis.
c. hypostatic pneumonia.
d. respiratory alkalosis.
C
Hypostatic pneumonia is a result of decreased physical mobility and is the most common hospital acquired disorder in immobilized patients.
The culturally competent nurse is aware that the American Indian medicine techniques are very significant to the patient. This medical intervention involves: (Select all that apply.)
a. healing ceremonies.
b. rituals performed by highly trained medicine people.
c. burning of sweet grass.
d. purging with minerals.
e. drums to align the patient’s heart with Mother Earth.
ABCE
The American Indian medicine techniques involve many specific ceremonies and rituals performed by highly trained medicine people. The burning of herbs, shaking rattles, and drumming realigns the patient with Mother Earth.
A form of alternative therapy that is used by more than 70% of the world’s population for treatment of disorders with botanicals is _________.
herbal therapy
phytotherapy
Herbal therapy (phytotherapy) is a system of herbal applications used to treat a wealth of disorders and is used by 70% of the world’s population.
What is Postural Hypotension?
What would you tell your patient who is experiencing this to do if they need to get out of bed?
Please use the call bell before getting up due to the patient being at risk for falls.
A patient is scheduled to have biofeedback therapy for migraine headaches. On arrival to the clinic, the patient appears anxious and fearful and tells the nurse that she does not want electric shocks. The most reassuring response by the nurse is:
a. “Don’t worry; this will not hurt a bit.”
b. “Didn’t the doctor explain this procedure to you?”
c. “There are no electrical shocks involved; the doctor is looking at your body’s activity.”
d. “You seem too anxious for this procedure. Let’s reschedule it at another time.”
C
Biofeedback involves applying electrodes to the body to look at the internal activity, so that the patient can gain control of involuntary activity.
An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurse’s best intervention would be to:
a. notify the charge nurse of possible infection.
b. wipe off drainage with a damp wash cloth.
c. assure the patient that such drainage is expected.
d. cover the pin with several gauze pads and tape securely.
C
Clear fluid drainage from pin sites is expected. The fluid can be removed with a sterile swab.
The nurse preparing the surgical patient’s room for the patient’s return from the postanesthesia unit should: (Select all that apply.)
a. fan fold the sheets on the near side of the bed.
b. lower the bed for easy transfer of the patient.
c. place an IV pole at the head of the bed.
d. gather an emesis basin, tissues, and a small towel.
e. collect extra dressing supplies and place them on the bedside table.
CD
The postsurgical room should be prepared with the sheets fan folded on the far side of the heightened bed. IV poles, emesis basins, oxygen, and suction equipment should be ready to use; a thermometer, sphygmomanometer, and stethoscope should be available.
To help prevent surgical site infections in the diabetic patient, the glycemic should be maintained with a blood glucose of less than _____ mg/dL.
200
A diabetic patient can be better protected from surgical site infection by maintaining blood glucose below 200 mg/dL.
What is included in the assessment when you are collecting vital signs?
what can you use as two patient identifiers
body temp
pulse for a full minute (apically)
respirations
blood pressure
pain level
Name and DOB
A patient asks the nurse about the difference between manipulative and body-based methods and mind–body therapies. The nurse’s correct response is that:
a. manipulative and body-based methods involve touching or manipulation, and mind–body therapies deal with the mind’s ability to affect the body.
b. mind–body therapies involve touch and manipulation, and body-based methods involve the mind’s ability to affect the body.
c. mind–body therapies involve the use of herbal remedies, whereas manipulative and body-based methods deal with touch.
d. an example of manipulative body-based methods is biofeedback, and an example of mind–body therapies is massage.
A
Manipulative and body-based methods involve touching, such as in chiropractic therapy, and mind–body therapy is the mind working to heal the body, such as with imagery.
The nurse explains that an air-fluidized mattress would not be advocated for the patient with:
a. a spinal cord injury.
b. recurrent pressure ulcers.
c. burns that have been newly grafted.
d. severe arthritis.
A
Air-fluidized therapy is not recommended for patients with unstable spines or for those who are ambulatory.
The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: (Select all that apply.)
a. pressure injuries.
b. loss of bone mass.
c. urinary infection.
d. pneumonia.
e. permanent loss of function.
ABDE
Immobilization can cause pressure injuries, loss of bone mass, pneumonia, and possible permanent loss of function of the immobilized part. Although urinary infections are common, immobility is not their cause.
The nurse places Dakin solution in a wound to accomplish chemical ___________.
debridement
Dakin solution is placed in a wound to destroy the necrotic tissue so that granulation tissue can form to heal the wound (debridement).