Cognition, Stress, & Coping
The nurse asks an elderly client, "What is your name and today's date? Can you tell me where you are?" What is the nurse assessing?
What is the client's level of orientation?
The nurse must irrigate the ear of a 4-year-old child. How would the nurse pull the pinna to straighten the child’s ear canal?
What is down and back?
What is the expected normal adult urinary output in mL/hr?
What is 30mL/hr?
Skin disease that only effects the top layer of the skin.
What is contact dermatitis?
What type of pain relief measures can be delegated to unlicensed assistive personnel?
Non-pharmacological measures that can include dstraction, positioning, and personal care skills.
The nursing diagnosis for a client is acute confusion related to infection as evidenced by alteration in cognitive function. Name an appropriate nursing intervention specific for this diagnosis.
What is reorienting the client to person, place, time, and situation every time you enter the room?
The nurse is conducting a focused assessment of a client with suspected hearing loss. While asking questions, the family member in the room is answering for the client. Who should be answering the questions?
What is the patient?
A high-fiber diet helps to promote normal bowel function. Name foods that are high in fiber?
What are fruits and vegetables?
The word that describes wound drainage that is made up of pus and blood.
What is purosanguineous?
The client tells the nurse he has been fatigued, easily distracted, and irritable. These are signs and symptoms of what?
What is sleep disorders?
How do you know if your client's confusion is clearing or resolving?
What is they are A & O x 4?
These two are clinical manifestations of hearing loss and NOT diseases. These can be caused my many things, including certain drug toxicities?
What is tinnitus and vertigo?
The program that helps clients with bladder or bowel incontinence regain control over a period of time by establishing set elimination intervals and changes made in stages.
What is a bladder or bowel training program?
Rupture of one or more layers of a wound occurring from the inflammatory phase of healing.
What is dehiscence?
The nurse administers pain medication at 1000. What time will the nurse reassess the client's pain?
What is between 1030-1100?
What is the most important thing to remember when caring for a confused client?
What is safety?
Type of hearing loss caused by an obstruction.
The nurse is assessing bowel sounds and hears high-pitched, gurgling sounds, about 5-15 gurgles per minute. How will the nurse document this?
What is normal bowel sounds?
A client with decreased sensation that is not aware of pressure feeling.
The amount of time you can leave heat or cold therapy in place.
What is 15 minutes?
This is the first indicator that something may be happening with your client.
What is change in mental status?
Name the 5 steps of an otoscopic exam.
1. Choose correct size speculum.
2. Have client tilt head to side not being examined.
3. Straighten the ear canal (Adult: Pinna up and back; Children: Pinna down and back).
4. Insert speculum and look for foreign objects.
5. Observe tympanic membrane mobility.
The type of bowel sounds you expect to hear in a client with paralytic ileus?
What is absent bowel sounds?
(And the belly will be distended, client will be c/o N/V and will need a NG tube placed)
A pressure injury described as an area of skin that is intact, purplish or blue color, and may be painful.
What is a deep tissue pressure injury.
The opioid reversal agent (antidote).
What is Narcan (Nalaxone)?