Nursing Acceleration Challenge Exam (NACE) I PN-RN: Foundations of Nursing Practice/Key Questions with 100% Correct Answers. An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet basic standards for hygiene, how frequently

Nursing Acceleration Challenge Exam (NACE) I PN-RN: Foundations of Nursing Practice/Key Questions with 100% Correct Answers. An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet basic standards for hygiene, how frequently should the patient be bathed? Biweekly Weekly Two to three times weekly Daily Two to three times weekly While adults don't usually need daily baths, they should bathe two to three times weekly. Grab bars, shower or tub seats, tub mats, handheld showers, and proper heating (to avoid chilling the patient) can facilitate more frequent bathing. Mild soap and bath oil may reduce the drying of skin. Patients who are fearful of tubs and showers, common with dementia, may receive a sponge bath or Comfort Bath with premoistened, warmed washcloths. Thick-handled toothbrushes or electric toothbrushes may facilitate mouth care. At which time of day are patients with cognitive impairment usually MOST sensitive to sensory overload? Late evening Noon Afternoon Early morning Afternoon Many people are more sensitive to sensory overload in the afternoon when cortisol levels are highest. Sensory overload most often affects those with cognitive impairment or those in stressful situations. Excess noise and activity can cause distress, agitation, confusion, and delirium. Sensory deprivation occurs when there is too little environmental stimulation because of reduction in sensory input because of hearing or vision deficits, inability to recognize sensory input because of cognitive impairment, or a boring environment. Sensory deprivation can contribute to confusion, disorientation, and depression. Terms in this set (15)  Which of the following is characteristic of nociceptive pain? Burning, stabbing, or shooting pains Diffuse or cramping pain Acute aching or throbbing pain localized to the site of injury Association with chronic conditions such as diabetes or cancer Acute aching or throbbing pain localized to the site of injury Nociceptive pain usually correlates with the extent and type of injury: the greater the injury, the greater the pain. It may be procedural pain (related to wound manipulation and dressing changes) or surgical pain (related to the cutting of tissue). It may also be continuous or cyclic, depending upon the type of injury. This type of pain, often described as aching or throbbing, is usually localized to the area of injury and resolves over time as healing takes place, and it usually responds to analgesia. According to the three-step World Health Organization (WHO) "analgesic ladder," a patient complaining of moderate to severe pain unresponsive to NSAIDs may require which of the following medications? Morphine Demerol Codeine Acetaminophen Codeine Step 1: Mild to moderate pain is treated with aspirin, acetaminophen, and NSAIDs. Step 2: Moderate to severe pain unrelieved by Step 1 medications may need opioids, such as codeine, tramadol, or Percocet. Step 3: Severe pain without relief from Step 1 or Step 2 medications may need stronger opioids, such as morphine, Dilaudid, or MS-Contin Which type of precautions is indicated for a patient with a surgical-site infection and purulent discharge? Contact and droplet Airborne Droplet Contact Contact Which of the following injection sites is the BEST choice for intramuscular (IM) administration of 3 mL of medication for a welldeveloped adult female of normal weight? Deltoid Vastus lateralis Dorsogluteal site Ventrogluteal site Ventrogluteal site The ventrogluteal site is the preferred IM injection site because there is little danger of injecting into fatty tissue, large nerves, or blood vessels. In a well-developed adult, up to 4 mL can be safely injected. The dorsogluteal site is the least preferred site because of its proximity to the sciatic nerve and large blood vessels and increased fat deposits. The vastus lateralis site is also good because it lacks large nerves or large blood vessels. The deltoid site is usually avoided because of the small muscle size and the proximity of the radial nerve and artery. Injections to the deltoid should be limited to 1 mL. A burn patient is upset and argues loudly with the nurse, refuses wound care, and states that the treatment is too painful. Which response is an example of therapeutic communication? "You should be happy that the burns are healing so well" "You should stop arguing with the nurses" "Everyone gets upset at times" "Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" "Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" Collaborating with the patient to find a solution to a problem is an example of therapeutic communication. The other responses are nontherapeutic and can block effective communication. Saying "Everyone gets upset at times" devalues the patient's feelings. "You should stop arguing with the nurses" is a negative judgment that may anger the patient more and does not deal with the real issue. Saying "You should be happy the wound is healing" provides unwanted advice and ignores the patient's concerns. According to Maslow's hierarchy of needs, which of the client's needs must be met FIRST? Belonging and self-esteem Physiological Safety and security Self-actualization Physiological Physiological needs must be met first. Abraham Maslow stated that human behavior is motivated by needs, and that there is a hierarchy of needs that begins with basic needs and progresses to personal needs. People may not progress in one direction from one need to another, but movement may be in multiple directions in a lifelong process of working toward selfactualization, which requires creativity and some degree of freedom. Failure to develop toward self-actualization may result in depression and feelings of failure. A bed-bound patient has a 1.5inch foam overlay over her mattress. The nurse places her hand under the overlay and finds that the foam overlay has compressed to 0.75 inch. What does this indicate? Excess wear Adequate support Bottoming out Moisture retention Bottoming out Support surface material should provide at least one inch of support under areas to be protected when in use to prevent "bottoming out." (Check by placing a hand palm-side up under the overlay and below the pressure point.) Static support surfaces are appropriate for patients who can change position without increasing pressure to an ulcer. Dynamic support surfaces are needed for those who need assistance to move or when static pressure devices provide less than one inch of support. A patient who is a Jehovah's Witness needs a transfusion of packed red blood cells because of blood loss, but his religion prohibits blood transfusions. Which of the following is the correct action? Tell the patient that he may die without the transfusion Provide full information and the reasons for the transfusion Assume the patient will not accept a transfusion and report this to the physician Tell the patient that his health is more important than religious beliefs Provide full information and the reasons for the transfusion It's important to approach the patient/family with full information and reasons for the transfusion or blood components without being judgmental, allowing them to express their feelings. One should never assume that an individual would refuse blood products based on religion alone. Jehovah's Witnesses can receive fractionated blood cells, thus allowing hemoglobinbased blood substitutes. The following guidelines are provided to church members: When the nurse enters the room of a patient whose death is imminent, the daughter states, "I can't stay in the room when Dad dies! I can't stand the thought!" Which of the following is the BEST response? "I'll stay with him, and you can come and go as you feel comfortable" "Is there someone else who can stay with him?" "Your father would want you with him" "You will regret it if you don't" "I'll stay with him, and you can come and go as you feel comfortable" The nurse should remain supportive and nonjudgmental. Saying "I'll stay with him, and you can come and go as you feel comfortable" supports the daughter's stated desire while still leaving open the opportunity for her to spend time with her father during the death vigil. People react in very different ways to death, and many people have never seen a deceased person and may be very frightened. While many people find comfort in being with a dying friend or family member, this should never be imposed on anyone. Which of the following terms is used to describe the biological effects of drugs over time? Half-time Pharmacokinetics Effect-site equilibrium Pharmacodynamics Pharmacodynamics Pharmacodynamics relates to the biological effects (therapeutic or adverse) of drug administration over time. Considerations include drug transport, absorption, means of elimination, and half-life. Pharmacokinetics relates to the effect the body has on the drug, considering the route of administration, absorption, dosage, frequency of administration, distribution, and serum levels achieved over time. The half-time is the time needed to reduce plasma concentrations to 50% during elimination. Usually the equivalent of five half-times is needed to completely eliminate a drug or achieve steady-state plasma concentrations if giving doses intermittently. The effect-site equilibrium is the time between administration of a drug and the clinical effect. When determining the burden of proof for acts of negligence, how would risk management classify willfully providing inadequate care while disregarding the safety and security of another? Comparative negligence Gross negligence Negligent conduct Contributory negligence Gross negligence Gross negligence. Negligence indicates that proper care has not been provided, based on established standards. Reasonable care uses a rationale for decision making in relation to providing care. Types of negligence include the following: Negligent conduct indicates that an individual failed to provide reasonable care or to protect/assist another, based on standards and expertise. Gross negligence is willfully providing inadequate care while disregarding the safety and security of another. Contributory negligence involves the injured party contributing to his/her own harm. Comparative negligence attempts to determine what percentage of negligence is attributed to each individual involved. Which of the following is a legal document that specifically designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent? Do-not-resuscitate order General power of attorney Advance directive Durable power of attorney Durable power of attorney The legal document that designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent is a durable power of attorney. This is a type of advance directive, which can include living wills or specific requests of the patient regarding treatment. A do-not-resuscitate order indicates that the patient does not want resuscitative treatment for terminal illnesses or conditions. A general power of attorney allows a designated person to make decisions for a person over broader areas, including financial.