Knowledge Base
You are assessing an older female, age 80, in the bed. You determine that she is at the highest risk for falls. Which intervention is the most important to implement?
A. provide bedside commode along with the call light in reach
B. have a sitter
C. have the bed alarm on for the when the patient gets out of the bed
D. put the high risk sign on the door
A
A preceptor and new hired nurse are reviewing mobility and gait issues. Which of the following observations by the newly hired nurse indicates the client is at risk for fallling?
the client requests stand-by assistance while ambulating
the client uses the handrails in the bathroom to stand up
the client has a shuffling gait up and down the hallway
the client has an assistive device that was left by a family member
the client has a shuffling gait up and down the hallway
nonpharmacological interventions for osteoarthritis are:
alternating heat and cold packs
Who is at the greatest risk for developing osteoporosis?
very tall and lengthy Canadian woman who attends crossfit
middle aged man who jogs regularly
smaller framed man who smokes and prescribed fluticasone
small framed woman who eats a variety of yogurt daily and supplements vitamin D
smaller framed man who smokes and prescribed fluticasone
A patient most recently had eye surgery for cataracts and given instructions for discharge. Which statement made by the client would suggest a correct understanding?
"I should expect to have moderate bruising of my eyelid for the next 72 hours."
"It is normal to experience a reduction in the vision in my eye for the next 48 hours following surgery."
"I will avoid tying my shoes for several weeks following my surgery."
"I will be able to take a shower in 2 days."
I will avoid tying my shoes for several weeks following my surgery
The nurse is caring for a client with a history of fractures that recently had a repair of her hip. Which would be considered a priority nursing diagnosis?
A. chronic pain
B. fatigue related to surgical process
C. decreased mobility related to surgical procedure
D. risk for constipation related to administration of medications
C
A patient is suspected to have retinal detachment. Which statement made by the patient suggests the possibility of the diagnosis?
Feels like a curtain has covered over my eye
I woke up with floaters
I have sudden loss of vision and its foggy
I have a halo
feels like a curtain has covered over my eye
Education for patients with osteoporosis for safe home care:
remove rugs from the floors, proper lighting, have necessary items close in reach
The nurse is assigned to a number of patients all of whom are experiencing pain. Which patients would most likely be treated inadequately for pain?
patient with expressive aphasia
patient undergone a laparoscopic procedure
patient with chronic gout
patient with spinal cord injury
patient with expressive aphasia
List a way to stop the progression of the disease osteoarthritis
exercise such as swimming and low weight bearing exercises
The student nurse is caring for a patient who is considered high risk for falling and will not stay in bed despite orders. The PCP has placed an order for side rail restriants. Which of the following would be considered?
1/2 length rail
2 full rails
3 half length rails
1 full length rails
2 full rails
If a patient has gout, you would expect which medication for the physician to order?
colchicine
What would be recommended for patients with neuropathic pain?
toradol
gabapentin
morphine
hydrocodone
gabapentin
You are assessing a 75 year old who has a long standing history of arthritic pain. Both the heart rate and blood pressure are elevated. What should the nurse implement first as being the possible cause of the fluctuating vitals?
administer NSAID
provide hypnotic distraction
assess whether the patient needs pain medication
wait an additional 5 minutes to recheck the vital signs for validity
assess whether the patient needs pain medication
The nurse is caring for a patient receiving morphine via the epidural route. Which actions by a student nurse who is precepting, requires follow up?
Notifying the primary care if the client develops urinary changes
obtaining a prescription for naloxone should the patient have respiration distress
administering amitriptyline as an added therapy
assessing the patient's blood pressure for hypotension following administration
administering amitriptyline as an added therapy
The charge nurse is reviewing the incident with a newly hired nurse in which an assigned older client was injured. Which of the following statements made by the new nurse requires immediate follow up?
the client fell trying to get up from the chair without using the call light for assistance
the clinet fell during shift report and was assessed prior to getting the client back to the bed
the client was trying to reach their wheelchair after using the bedside commode
the client was instructed to call if they needed help out of bed but refused to do so
The client was trying to reach their wheelchair after using the bedside commode
Common cause of macular degeneration
genetic predisposition and smoking
The most effective way to assess pain on an elderly client returning from surgery, who is alert and oriented?
facial expression
ask "are you having pain"
monitor vital signs
ask the client to rate pain 0-10
ask the client to rate pain 0-10
What would the nurse expect to observe of a patient with open angle glaucoma?
mild eye aches
fixed dilated pupils
frequent complaints of "tired eyes"
which is most important for a patient diagnosed with osteoarthritis presenting with a low grade fever and bilateral joint pain?
discuss the purpose of range of motion exercises
teach about joint protection activities
discuss increasing the dose of anti-arthritic drugs
prepare the client to have lab studies performed
prepare the client for lab studies
The nurse is caring for an older client who is suffering from mobility issues. which of the following statements is correct regarding the use of assistive devices?
canes do not require special training from a physicial theraist to be used
smart canes provide feedback to the client and can detect when a fall has occurred
a walker can be used when climbing stairs by all clients with proper training
it is advisable to adapt borrowed equipment from a friend to reduced cost
smart canes provide feedback to the client and an detect when a fall has occurred
As the home health nurse teaches a patient with impaired vision about home safety. Which statements made by the patient suggests further teaching?
"I have arranged for bright lighting to be installed in my bathroom"
"I will continue to use a razor to shave"
"I have labeled cleaners and toxic agents with large letters."
" I will make sure that my furniture is not rearranged"
I will continue to use a razor to shave
The patient with rheumatoid arthritis would exhibit which manifestations?
low grade fever, fatigue, anorexia with weight loss
Patient is post cataract surgery. What should the patient report immediately to the nurse?
clear discharge
moderate to severe pain
redness to the eye
scratchy feeling to the eyelid
moderate to severe eye pain
You are caring for an older client who is postoperative hip replacement. To manage pain, you would administer:
PO pain medication following ambulation
extended release medication for breakthrough pain
pain medication when the pain level is at it highest
opioid analgesics and titrate doses slowly
opioid analgesics and titrate doses slowly