Solutions
A female pt who is having a MI complains of pain
that is situated in her jaw. The nurse documents
this as what type of pain?
A. Transient pain
B. Superficial pain
C. Phantom pain
D. Referred pain Correct Answers D
A nurse asks a pt to close her eyes, state when she
feels something, and describe the feeling. The
nurse then brushes the pt's skin w/ a cotton ball,
and touches the pt's skin w/ both sides of a safety
pin. Which sense is the nurse assessing?
A. Gustatory
B. Olfactory
C. Tactile
D. Kinesthetic Correct Answers C
A nurse assesses a pt's body temp in the late
afternoon at 37.2 degrees C (99 degrees F). What
would be the nursing action r/t this slight elevation
in temp?
A. Assess the pt for infection
B. Record the temp as a normal finding
,C. Call the physician for an order for antipyretics
D. Decrease the room temp Correct Answers B
A nurse caring for pts in a busy hospital
environment should implement which
recommendation to promote sleep?
A. Keep the room light dimmed during the day
B. Keep the room cool
C. Keep the door of the room open
D. Offer a sleep aid medication to pts on a regular
basis Correct Answers B
A nurse caring for pts in a LT care facility is
implementing interventions to help promote sleep
in elderly pts. Which action is recommended for
these pts?
A. Increase physical activities during the day
B. Encourage short periods of napping during the
day
C. Increase fluids during the evening
D. Dispense diuretics during the afternoon hours
Correct Answers A
A nurse formulated the following nursing diagnosis
for an 8-month-old infant: Disturbed Sensory
Perception: Sensory Deprivation r/t inadequate
parenting. Since that diagnosis was made, both
parents have attended parenting classes. However,
, both parents work while the infant stays w/ her
86yo grandmother, who has reduced vision. The
parents provide appropriate stimulation in the
evening. At an evaluation conference at the age of
11 months, the infant lies on the floor sucking her
thumb and rocking her body. Her facial expression
is dull and she vocalizes only in a low monotone.
Which statement accurately reflects evaluation
about the child's sensory deprivation?
A. The infant's parents lack motivation to provide
necessary stimulation
B. The grandmother is unable to improve the
infant's care
C. The infant's sensory deprivation is still severe
D. This is normal behavior for an 11-month-old
infant Correct Answers C
A nurse formulates the following diagnosis for an
elderly pt who is having trouble getting to sleep at
night: Disturbed Sleep Pattern: Initiation of Sleep.
Which of the following nursing interventions would
the nurse perform r/t this diagnosis? Select all that
apply.
A. Arrange for assessment for depression and
treatment
B. Discourage napping during the day
C. Decrease fluids during the evening
D. Administer diuretics in the morning