Maslow's and Stress
A patient with terminal cancer is willing to try new therapies. Which stage of Kubler-Ross Stages of Grieving is the patient experiencing?
1) Denial
2) Depression
3) Bargaining
4) Acceptance
What is bargaining?
A nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range of motion?
What is every 2 hours.
A nurse is caring for the following group of patients with infections. Which infection is classified as hospital-acquired infection?
1) Respiratory infection contracted from a visitor
2) Vaginal canal infection in a postmenopausal woman
3) Urinary tract infection in a patient who is sedentary.
4) Wound infection caused by unwashed hands of a caregiver
What is wound infection caused by unwashed hands of a caregiver?
What is being communicated when the nurse leans forward during a patient interview?
1) Aggression
2) Anxiety
3) Interest
4) Privacy
What is interest?
What event in a person's life has the greatest potential to contribute to stress-related illness?
1) Retirement
2) Pregnancy
3) Adoption
4) Divorce
What is divorce?
Chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the order?
1) Emphysema
2) Osteoporosis
3) Cystic fibrosis
4) Chronic bronchitis
What is osteoporosis?
The nurse is caring for a patient with high fever secondary to septicemia. The primary health-care provider orders a cooling blanket (hypothermia blanket). Through which mechanism does the blanket achieve heat loss?
1) Radiation
2) Convection
3) Conduction
4) Evaporation
What is conduction?
A nurse is conducting a focused interview to complete an admission history. Which interviewing technique should the nurse use?
1) Probing
2) Clarification
3) Direct questions
4) Paraphrasing statements
What is direct questions?
The nurse is assessing a patient who is experiencing prolonged stress. What serious complication should the nurse monitor the patient for?
1) Altered sleeping
2) Impaired immunity
3) Increased muscle tension
4) Decreased intestinal peristalsis
What is impaired immunity?
A nurse caring for a patient with NG tube for gastric decompression. Which nursing action takes priority?
1) discontinuing the wall suction when providing nursing care.
2) Positioning the patient in the semi-Fowler position
3) Instilling the tube with 30 ml of air every 2 hours.
4) Caring for the nares at least every 8 hours.
What is 2.
Which does the nurse determine is a secondary line of defense against infection?
1) Mucous membrane of the respiratory tract
2) Urinary tract environment
3) Integumentary system
4) Immune response
What is immune response?
Which interviewing skill is used when the nurse says, " You mentioned before that you are having problems with your colostomy."
1) Focusing
2) Clarifying
3) Paraphrasing
4) Acknowledging
What is focusing
The nurse is assessing a patient who is experienced an emotional stress. which most common response should the nurse anticipate the patient will exhibit?
1) Anger
2) Denial
3) Anxiety
4) Depression
What is anxiety?
Nurse is assessing a patient's risk for thrombus formation associated with impaired mobility.
What factors would contribute?(select all that apply)
1) compression of small vessels in the legs
2) orthostatic hypotension
3) hypostatic pneumonia
4) venous pooling
1 and 2
A nurse is caring for a group of hospitalized patients. Which should the nurse do first to prevent patient infections?
1) Provide small bedside bags to dispose of used tissues.
2) Encourage staff to avoid coughing near patients.
3) Administer antibiotics as prescribed.
4) Identify patients at risk.
What is identify patients at risk.
This is an important first step in prevention of infection. Specific precautions might need to be made.
A patient states, "Do you think I have cancer?" The nurse responds, "What did the doctor tell you?" Which interview approach did the nurse use?
1) Paraphrasing
2) Confrontation
3) Reflective technique
4) Open-ended question
What is open-ended question?
A nurse is assessing patients in the PACU. For which of the following physiological responses to stress should the nurse monitor in a patient? (select all that apply?)
A) dilated pupils
B) Slow, bounding pulse
C) Delayed response time
D) Inability to concentrate
E) Rapid, shallow breathing
F) Increased muscle tension
A,E,F
A nurse is providing for the hygiene and grooming needs of an obese patient who easily becomes short of breath when moving. Which nursing interventions are important? (select all that apply)
1) Administer Oxygen during provision of care.
2) Maintaining the bed in a high-Fowler position.
3) Assessing the patient's response to the activity.
4) Bathing areas that the patient cannot reach.
5) Providing rest periods every ten minutes.
3 and 4
Which patient information collected by the nurse reflects a systemic response to a wound infection? Select all that apply
1) increased body tempature
2) increased heart rate
3) leukocytosis
4) exudate
5) edema
6) pain
What is 1,2,& 3.
Which nursing action should the nurse implement when speaking with a patient whose hearing is impaired? (select all that apply)
A) limit background noise
B) exaggerate lip movements
C) lower the pitch of your voice
D) stand directly in front of the patient when speaking
E) raise the volume of your voice while speaking directly toward the patient's good ear.
A,C,D