Sensory Perception
This sense allows a person to identify an object by its size, shape, and texture without looking at it.
What is stereognosis?
This communication framework is used when calling a healthcare provider to report a change in a client's condition.
What is SBAR?
This type of care focuses on improving quality of life for clients with serious illnesses and can begin at any stage of the disease.
What is palliative care?
A home care client has both visual and hearing deficits. What is the nurse's highest priority when planning care?
What is safety?
A provider orders 1000 mL of normal saline to infuse over 8 hours. Calculate the IV pump rate.
What is 125 mL/hr?
A hospitalized client is legally blind. Name one nursing intervention that promotes the client's independence during hospitalization.
What is keeping the call light in a consistent location, describing the location of food on the meal tray, or knocking before entering the room?
Which part of SBAR includes asking the provider to order a CBC and blood cultures?
What is the Recommendation?
This is the highest nursing priority for a client who is actively dying.
What is pain management?
An older adult becomes confused shortly after being admitted to the hospital. What is the most likely reason?
What is the unfamiliar hospital environment may cause sensory overstimulation?
A provider orders 2000 mL of D5W to infuse over 20 hours. Calculate the IV pump rate.
What is 100 mL/hr?
This client is at the greatest risk for sensory overload: an outpatient having cataract surgery, an older adult on a geriatric unit, a client with chest pain in the ED, or a client in the ICU being treated for septic shock.
Who is the client in the ICU being treated for septic shock?
A client newly diagnosed with diabetes says they cannot give themselves insulin injections. What teaching strategy is most effective?
What is demonstrate the injection and have the client return-demonstrate (mimic the demonstration)?
A dying client's family asks if they should stay in the room. How should the nurse respond?
What is, "Please stay with your loved one and talk to them."?
A nurse is teaching a client. What should the nurse assess before developing the teaching plan?
What should the nurse assess before developing the teaching plan?What is the client's learning needs and what the client wants to know?
The nurse is teaching a client immediately after receiving IV pain medication. The client repeatedly falls asleep during the education session. What should the nurse do?
What is postpone teaching until the client is alert and ready to learn?
An older adult wears a hearing aid in the left ear. What is the best way for the nurse to communicate with this client?
What is face the client and speak in a low-pitched voice?
A client correctly reads a nutrition label and explains how a balanced diet promotes healing. Which learning domain is being demonstrated?
What is the cognitive domain?
Before providing culturally competent end-of-life care, what should the nurse determine first?
What are the client's cultural beliefs, values, and preferences?
A client with hearing loss is admitted to the hospital. What is the priority nursing intervention to improve communication?
What is face the client while speaking in a low-pitched voice and reduce background noise?
During bedside report, a client begins crying after hearing the new diagnosis discussed. What should the nurse do first?
What is acknowledge the client's emotions and use therapeutic communication before providing additional information?
Impacted cerumen causes this component of sensation to be impaired.
What is sensory reception?
When beginning health education for an older adult with arthritis, what should the nurse determine first?
What is find out what the client wants to know?
A client has a valid DNR order and experiences cardiac arrest. What should the nurse do?
What is make no attempt to resuscitate the client?
A visually impaired client is admitted to the hospital. Name two nursing interventions that promote safety and independence.
What are keep the call light in the same location, orient the client to the room, describe the meal tray, knock before entering, and remove obstacles? (Any two.)
A client receiving hospice care develops increasing shortness of breath and severe anxiety. Which nursing action has the highest priority?
What is relieve the client's symptoms and promote comfort rather than focusing on curative treatment?
A client returning from surgery is unconscious. This is the appropriate way for the nurse to communicate with the client.
What is speak to the client in a normal tone of voice because hearing may still be intact?
During motivational interviewing, the nurse wants to encourage the client to identify personal goals. What is the best opening question?
What is, "What things are most important to you and your health?"
A terminally ill client says, "My situation is hopeless." Name one nursing intervention that promotes hope.
What is sit with the client, encourage discussion of feelings, or hold the client's hand?
A client has a valid DNR order and suddenly has no pulse or respirations. What is the nurse's priority action?
What is honor the DNR and do not initiate CPR?
A family asks why the nurse continues talking to their unconscious loved one. What is the nurse's best response?
What is explain that hearing may remain intact until late in the dying process, so speaking calmly can provide comfort?
A home health client has both severe vision and hearing impairments. This is the nurse's highest priority when planning care.
What is safety?
The nurse uses familiar, everyday examples and teaches only when the client is alert and focused. Which learning principle is the nurse addressing?
What are attention and concentration?
Following an unsuccessful resuscitation, what nursing intervention best helps the family begin the grieving process?
What is encourage the family to openly express their emotions?
A terminally ill client reports severe pain despite prescribed medication. What should the nurse do first?
What is assess the pain and intervene to improve pain control, because pain management is the highest priority in end-of-life care?
The nurse is caring for four clients. Which client should the nurse assess first? 1. A client with cataracts requesting assistance to the bathroom. 2. A client with hearing aids requesting new batteries. 3. A hospice client whose pain increased from 3/10 to 9/10 despite medication. 4. A client awaiting discharge who wants more education.
Who is the hospice client with uncontrolled pain?
A client tells the nurse, "I don't even notice the IV pump beeping anymore." What sensory concept does this demonstrate?
What is sensory adaptation?
After providing education to a client, what is the most important thing for the nurse to document?
What is evidence that learning has occurred?
A client's adult child arrives moments after the client's death and says, "I wish I could have been here so my dad wouldn't die alone." What is the nurse's most therapeutic response?
What is, "I will close the door so you can spend some quiet time at the bedside."?
A nurse has just completed client education about insulin administration. What is the priority action before documenting the education?
What is have the client perform a return demonstration to verify learning?
A nurse has completed client education on a new medication. The client correctly explains the medication but is unable to demonstrate how to use the inhaler. What should the nurse conclude?
What is cognitive learning has occurred, but psychomotor learning has not yet been achieved, so additional teaching and return demonstration are needed?