NR 341 COMPLEX ADULT HEALTH EXAM 1 QUESTIONS WITH RATIONALES

NR 341 COMPLEX ADULT HEALTH EXAM 1 QUESTIONS WITH RATIONALES A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A. A client wants to know the current time while there is a clock on the wall. B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees C (78 F). D. A client refuses to get out of bed and has no motivation to attend to daily hygiene. -Correct Answer= B. (Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.) A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A. Decreased auditory and visual acuity. B. Decreased display of emotion. C. Personality traits that are opposite of original traits. D. Forgetfulness gradually progressing to disorientation. -Correct Answer= D. (Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.) A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.) A. Ability to perform calculations B. Level of consciousness C. Recall ability D. Long-term memory E. Level of orientation -Correct Answer= A, C, E. (Evaluating the client's ability to perform calculations is an included component of an MSE. Determining the client's level of consciousness is not a component of an MSE. Identifying the client's ability to recall a list of objects or words is an included component of an MSE. Evaluating long-term memory is not a component of an MSE. Determining the client's level of orientation is an included component of an MSE.) A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, " I want to go home; my husband is waiting for me to cook dinner. "Which of the following responses by the nurse is appropriate? A. " this is where you live now." B. " this is a safer place for you to live." C. "Tell me what you like to cook for dinner." D. "Your family said there is no one to care for you at home." -Correct Answer= C. (Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease means that the client is experiencing the later stages of the illness with moderately severe to severe cognitive decline. By asking the client to talk about what she likes to cook for dinner, the nurse is demonstrating validation therapy by asking the client to talk about the areas that concerned her. The nurse could continue the conversation by discussing how much the client misses her home and partner. Validation therapy helps clients who have cognitive disorders discuss their feelings about past events and people.) A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A. rotate assignment of daily caregivers. B. provide an activity schedule that changes from day to day. C. limit time for the client to perform activities. D. talk the client through tasks one step at a time. -Correct Answer= D (The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.) A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room with dim lighting D. A room containing personal belongings -Correct Answer= D (A room that contains several of the clients personal belongings assists in maintaining personal identity and provides a therapeutic environment) The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet response to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the clients behavior? A. he is hard of hearing B. pain C. confusion D. language barrier -Correct Answer= C (since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion) A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.) A. grooming B. long-term memory C. support systems D. affect E. presence of pain -Correct Answer= A, B, D (Grooming is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Long-term memory is included in an MSE which consists of appearance, behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Support systems are not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Affect is included in an MSE which consists of appearance, behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. The presence of pain is not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.) A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A. assist the client to the correct room. B. place the client in restraints. C. re-orient the client to time and place. D. move the client to a room at the end of the hall. -Correct Answer= A (assisting the client to the correct room protects both clients. It helps reorient the client who is unable to find her own room, and it prevents the other client from an invasion of her personal space.) A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. post a written schedule of daily activities. B. use an overhead loudspeaker to announce events. C. provide a consistent daily routine. D. allow the client to choose free time activities. -Correct Answer= C (A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.) A nurse is monitoring a client who is post operative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.) A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness -Correct Answer= A, B, D (Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious in response to the discomfort. Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain. Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal behaviors, that indicate pain. Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients who have pain. Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of pain.) A nurse is caring for a client who is one day post operative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? A. determine the time the client last received pain medication. B. Measure the clients vital signs, including temperature. C. ask the client to rate her pain on a scale of from 0 to 10. D. re-position the client and offer her a back rub. -Correct Answer= C (Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.) A nurse is planning care for a client who is post operative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) A. use of analgesics will eventually lead to addiction. B. each clients expression of pain may be different and individualized. C. Patient controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and tolerance can be assessed using a scale from 0 to 10. E. The client will express the feeling of pain both verbally and nonverbally. -Correct Answer= B, C, D, E (Use of analgesics will eventually lead to addiction is incorrect. The administration of analgesics does not lead to addiction. This is a common misconception about pain management.) A nurse is caring for a client your request prescription pain medication. Which of the following actions should the nurse perform first? A. re-position the client. B. administer the medication. C. determine the location of the pain. D. review the effects of the pain medication. -Correct Answer= C (The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.) A nurse is applying a cold compress for a client who has pain and minor swelling in a suture laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. inspecting the site for reduced swelling B. monitoring the clients pulse rate C. asking the client to rate the pain D. having the client perform range of motion of the affected arm -Correct Answer= C (Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness.) A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? A. set the pad's temperature to 47.2°C B. stop the treatment if the client's skin becomes red C. leave the pad in place for at least 40 minutes D. use safety pins to keep the pad in place -Correct Answer= B (The temperature setting for most aquathermia pads is 40° C (104° F). Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider. The heat application should last no longer than 30 min. Safety pins can puncture the pad and cause leakage. The nurse should use gauze or tape to keep the pad in place.) A nurse is caring for a client who is post operative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. vital sign measurement B. The clients self report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure -Correct Answer= B (Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.) A nurse is caring for a client who requires cold applications with an ice bag to reduce The swelling and pain of an angle injury. Which of the following actions should the nurse take? A. apply the bag for 30 minutes at a time. B. Reapply the bag 10 minutes after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin. -Correct Answer= A (The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.) A nurse is caring for a client who is post operative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) A. offer the client a back rub. B. Remind the client to use incisional splinting. C. Identify the clients pain level. D. Assist the client to ambulate. E. Change the client's position. -Correct Answer= A, B, C, E (Offer the client a back rub is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Assist the client to ambulate is incorrect. If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.) A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. vital signs B. self report of pain C. severity of the condition D. nonverbal behavior -Correct Answer= B (According to evidence-based practice, the most reliable indicator of pain is the client's self-report of pain. A pain intensity scale is a reliable tool to identify the client's pain level.) As stress increases, the person is more susceptible to changes in health such as increased risk for: -Correct Answer= infection, high-blood pressure, diabetes, and cancers True or false. Whether or not the person anticipated the stressor influences its effect. -Correct Answer= True Is it more difficult to cope with an expected or unexpected stressor? -Correct Answer= Unexpected Personal characteristics that influence the response to a stressor include: -Correct Answer= the level of personal control, presence of a social support system, and feelings of competence Compensation -Correct Answer= Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset Conversion -Correct Answer= Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (ex. difficulty sleeping, loss of appetite) Denial -Correct Answer= Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain Displacement -Correct Answer= Transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute (ex. you're having trouble with a relationship and take it out on a malfunctioning computer or slow internet) Identification -Correct Answer= Patterning behavior after that of another person and assuming that person's qualities, characteristics, and actions Dissociation -Correct Answer= Experiencing a subjective sense of numbing and a reduced awareness of one's surroundings Regression -Correct Answer= Coping with a stressor through actions and behaviors associated with an earlier developmental period Situational Stress -Correct Answer= arises from personal, job or family changes Examples of stress-producing illnesses: -Correct Answer= Chronic illnesses such as cancer, cardiac disease, diabetes, and depression How does being a caregiver for someone with a chronic illness (ex. Alzheimer's) impact a person? -Correct Answer= It is associated with stress in the caregiver How do cultural variations influence stress? -Correct Answer= Cultural variations produce stress, particularly if a person's values differ from the dominant culture in aspects of gender roles, family relationships, and religious beliefs Patients overwhelmed by life events are often: -Correct Answer= are often unable, at least initially, to act on their own behalf and require either direct intervention or guidance How can you better get a patient to share personal and sensitive information with you as their nurse? -Correct Answer= establish a trusting nurse-patient relationship How should you begin an assessment? -Correct Answer= open-ended question After beginning with an open-ended question, what should you assess next? -Correct Answer= he patient's perception of the event, available situational supports, and what he or she usually does when there is an unsolvable problem How can you determine if a patient is suicidal or homicidal? -Correct Answer= asking directly. For example, ask, "Are you thinking of hurting yourself or someone else?" What is important to know about your patient? -Correct Answer= their wants and needs What should you respect in all interactions with the patient? -Correct Answer= confidentiality and sensitivity of the information shared Nursing Assessment example questions for Patient Safety: -Correct Answer= • Do you have any thoughts of harming yourself or others? • Are you having difficulty with sleeping? Falling asleep? Staying awake? • Is there any change in eating patterns? • Have you had any accidents at home, in the car, at school, or on the job? Nursing Assessment example questions for Perception of Stressor: -Correct Answer= • What do you believe is stressing you right now? • What impact does this stressor have on your lifestyle? • How does this stressor impact you now? How will it impact you in the future? Nursing Assessment example questions for Available Coping Resources: -Correct Answer= • Which strategies have you used in the past to deal with stress? • Are you able to confide in friends or family? • What is relaxing for you? Nursing Assessment example questions for Maladaptive Coping Used: -Correct Answer= • Have you started drinking or smoking? • Do you use any over-the-counter or herbal medications? • Do you use any street drugs? Nursing Assessment example questions for Adherence to Healthy Practices: -Correct Answer= • How long since you saw a health care provider? • What is your exercise pattern? • Which type of meals do you eat? Are your meals regular? • Are you taking your prescribed medications as ordered? Objective findings to look for: -Correct Answer= - grooming and hygiene - gait - characteristics of the handshake - actions while sitting - quality of speech - eye contact - the attitude of the patient during the interview Before the interview begins with a patient or at the end, what should you always remember to do? -Correct Answer= obtain basic vital signs to assess for physiological signs of stress such as elevated blood pressure, heart rate, or respiratory rate What are some nonverbal signs that you should look for in a patient? -Correct Answer= anxiety, fear, anger, irritability, and tension in a patient who is experiencing ineffective coping What are some good outcome examples for a patient? -Correct Answer= patient engages in support group, family members are able to discuss loss together, caregiver participates in respite care Primary level of stress prevention includes: -Correct Answer= you direct nursing activities to identifying individuals and populations who may be at risk for stress (AKA the stress has not necessarily happened yet) Secondary level of stress prevention includes: -Correct Answer= actions directed at symptoms such as protecting the patient from self-harm (AKA the patient is already stressed, now what can I do to keep them safe & under control?) Tertiary level of stress prevention includes: -Correct Answer= help the patient readapt and can include relaxation training and time-management training (They're stressed, but now instead of just preventing harm, you're trying to help them cope and readapt) What is the first priority in all areas of nursing? -Correct Answer= safety of the patient and others in his or her environment Three primary modes of intervention for stress: -Correct Answer= 1. To decrease stress producing situations 2. increase resistance to stress 3. learn skills that reduce physiological response to stress (Line up with the levels of stress prevention) What is crucial involving home and work life for nurses? -Correct Answer= Making a clear separation between the two. (Strengthening friendships outside of the workplace, participating in creative activities for personal "recharging" of emotional energy, and spending offduty hours in interesting activities all help reduce compassion fatigue.) When a person is recovering from acute stress, what do they often report? -Correct Answer= spontaneously reports feeling better when the stressor is gone When a person is recovering from chronic stress, what is often the case for their recovery? -Correct Answer= The recovery from chronic stress occurs more gradually as the patient emerges from the strain In both acute and chronic stress, what can the nurse evaluate on the patient? -Correct Answer= evaluate the patient for the presence of new or recurring stress-related symptoms. must include the patient's perceptions of their symptoms and situations. The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal 5. Depression -Correct Answer= 3, 5 (PTSD usually happens in response to a traumatic event. Rising hormone levels signify that the patient is in the acute phase of stress, and this patient has long passed that. Return of vital signs to normal is seen with the acute stressor being taken away, and this patient is experiencing chronic stress) A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement. -Correct Answer= 1. When doing an assessment of a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the crash whenever she hears loud yelling or a sudden noise. The nurse recognizes this as . -Correct Answer= PTSD A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis. -Correct Answer= 3. (The tsunami is a naturally occurring disaster, which is a key characteristic of an adventitious crisis) During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help. 5. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking? -Correct Answer= 1, 2, 5 The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? 1. Loss of autonomy caused by health problems 2. Physical appearance, family, friends, and school 3. Self-esteem issues, changing family structure 4. Search for identity with peer groups and separation from family -Correct Answer= 4 (1 = elderly, 2 = school-aged children, 3 = preadolescent) A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "Let me help you two calm down a bit so I can take you to your daughter." -Correct Answer= 2, 4, 3, 1 (My rationales: 2 directly lets the parents know that their daughter is fine, which would help to calm them down and leave them with no wonder of "is my daughter okay?" 4 is second best because the parents will still get to see their daughter soon and it addresses that they are freaking out and probably shouldn't be, at least for the sake of their daughter. 3 would probably make them even more anxious as it does not tell them anything about the status of their child, but still would send someone out to them soon. 1 is just bad because you aren't doing anything to help them and you aren't even telling them who will help them.) After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which of the following are appropriate responses or actions of the nurse? (Select all that apply.) 1. "I know another patient whose colon cancer was cured by surgery." 2. Straighten the patient's bed and room 3. "Have you thought about how you are going to tell your family?" 4. "Would you like for me to sit down with you for a few minutes so you can talk about this?" 5. Sit quietly with the patient -Correct Answer= 4, 5 (Both of these are therapeutic approaches to this situation and allow the patient to lead the conversation without giving false hope, ignoring their concerns, or stressing them out further) A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "What do you mean when you say you can't go on any longer?" -Correct Answer= 4 (Though you should be direct in asking about suicide, the father did not explicitly give a hint that he was contemplating suicide. Putting the idea into his head might bring harm to the patient)