Nurs131 Final Revised Set Graded A+ Exam 2025

Nurs131 Final Revised Set Graded A+ Exam 2025 The nurses notes on the admission form that the patient has indication "no religious preference." What does this indicate to the nurse about the patient? a) does not follow the tenets of a specific faith b) is in denial about his religious beliefs c) doesn't believe in God or a "higher power" d) will not want to pray or visit with the chaplain - Correct Answer-a) does not follow the tenets of a specific faith Your pt is a 17 year old who lost her right lef in a MVA. After her parents leave, she asks you, "Why did God let this happen to me? I have always followed his commandments." Which action best depicts the "caring" aspect of SENC? a) "Let me call your parents back to support you." b) I think the chaplain can provide the support you need." c) cry with the pt as you hug her d) hold her hand, sit with her, & listen - Correct Answer-d) hold her hand, sit with her, & listen The student nurse has earned A's in all of her prerequisite courses. For the first exam in a nursing course, she earns a D and now feels that she may not be smart enough to become a nurse. What type of "loss" is the student experiencing? a) actual b) external c) physical d) perceived - Correct Answer-d) perceived Your 55 year old pt was just informed that she has metastatic pancreatic cancer and has 4 months to live. After the provider leaves, she says to you, "I don't want my family to know. But they have to know. Please don't tell them. Please tell me what to do, help me." What is your best response? a) "I know this is difficult for you. Take time to thin about it." b) "You should get a second opinion before you alarm your family." c) "Let me hold your hand to make you feel better." d) "Tell me how you are feeling right now." - Correct Answer-d) "Tell me how you are feeling right now" Nursing Nursing The pt is dying of cancer and can no longer swallow. the son states to the nurse, "You MUST give dad some water, he always drank a lot of water." The nurse's best response is a) "You sound very upset. Tell me more about your dad." b) "Your father is dying from cancer and water will not stop this process." c) "Research shows that withholding oral fluids decreases edema." d) "I will call the provider & get a prescription to insert a NG tube for the water." - Correct Answer-a) "You sound very upset. Tell me more about your dad." The hospitalized pt states, "I need to know when I'm going to be discharged. I'm so upset & worried that I'm missing work." The nurse knows: a) this is an example of "eustress" & no intervention is necessary b) this is an example of psychological stress & the pt should be placed on antidepressants c) this is an example of developmental stress & the pt should talk to someone his own age d) this is an example of distress & could affect the pt's health status - Correct Answer-d) this is an example of distress & could affect the pt's health status A pt who is taking atenolol (Tenormin) may not exhibit a rise in blood pressure & pulse during the alarm stage of the general adaptation syndrome a) true b) false - Correct Answer-a) true Tenormin is a beta-blocker (or otherwise a anti-hypertensive medication) The nurse should assess every pt to determine if stress reduction interventions should be part of the plan of care. The rationale for this action is that: a) there are more persons experiencing mental illness now than in the past b) life is so much more stressful than it has ever been c) the occurrence of stress in pts is unpredictable d) pts often develop maladaptive coping strategies - Correct Answer-c) the occurrence of stress in pts is unpredictable Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm and his blood pressure is 140/70 mmHg. Nursing actions should include which of the following? a) turn on the TV to provide distraction b) ask the pt if he would like to discuss his anxiety further Nursing Nursing c) close the blinds, dim the lights, and ask the pt what other measures would help him rest d) call the physician and obtain an order for an anti-anxiety medication for PRN use - Correct Answer-c) close the blinds, dim the lights, and ask the pt what other measures would help him rest For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care. a) true b) false - Correct Answer-a) true GCS correlates to the patient's ability to function. The lower the score, the more nursing intervention required. When conducting a weekly home visit with an older pt, the nurse realized the pt has not been adhering to his recommended medication schedule. What should the nurse do next? a) investigate why b) reprimand the pt for being noncompliant and explain how important it is to not miss dosages of medications c) explain the effects of missing dosages of certain medications d) evaluate the medication schedule - Correct Answer-a) investigate why It's important to understand why the pt hasn't been adhering to the scheduled med schedule Issues like vision, literacy, & side effects could be easily rectified if investigated A 4 year old patient resists going to sleep. To assist this pt, the best action to take would be: a) adding a daytime nap b) allowing the child to sleep longer in the morning c) maintaining the child's home sleep routine d) offering the child a bedtime snack - Correct Answer-c) maintaining the child's home sleep routine During rounds on the night shift, you note that a pt stops breathing for 1-2 minutes several times during the shift. This condition is known as: a) cataplexy b) insomnia c) narcolepsy d) sleep apnea - Correct Answer-d) sleep apnea Nursing Nursing What is missing from the documentation regarding the emptying of draining from a wound? "03/12/16 07:50: Hemovac drained serosanguinous fluid over 12 hours. No odor or perulent material noted at drainage site." a) amount drained b) AM or PM c) description of color at the drainage site d) materials used - Correct Answer-a) amount drained The nurse is working with a patient with low total protein & serum albumin levels. The patient presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation? a) increase cholesterol in the diet b) increase protein in the diet c) increase vitamin C in the diet d) increase fluid intake during the day - Correct Answer-b) increase protein foods in the diet A student nurse asks the nurse the difference between dehiscence & evisceration. Which would be the best explanation? a) dehiscence is an urgent complication that requires surgery ASAP; evisceration is not as urgent b) dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue c) dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue - Correct Answer-b) dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue 3 days after abdominal surgery, the nurse notes a 2cm area of erythema & swelling at the proximal end of the incision. The area is tender & warm to the touch. Staples are in tact along the incision, no obvious drainage. Temp 100.8 F. The nurse suspects: a) infection at the incisional site b) dehiscence of the wound c) hematoma under the skin d) formation of granulation tissue - Correct Answer-a) infection at the incisional site The nurse avoid placing a dressing that wraps around an extremity to prevent what complication? - Correct Answer-to prevent cutting off circulation Nursing Nursing The nurse irrigates top to bottom to prevent what complication? - Correct Answer-to prevent cross-contamination of infection in other areas of the wound Why should the nurse prevent packing the gauze tightly into the wound? - Correct Answer-to promote blood flow What assessments can you make for a dying patient? - Correct Answer-- determine funeral plans when ready for that conversation - determine if pt has advanced directives What nursing diagnoses could be used for someone experiencing loss, death, or grief? - Correct Answer-- caregiver role strain - risk for grieving As a nurse, how can you support your patient's loved ones when the patient is terminally ill? - Correct Answer-- have family help with care (if possible) - encourage questions - encourage visit to the chapel or to talk with clergy - explore coping mechanisms - provide anticipatory guidance - acknowledge & validate feelings of the pt & family - remind family members & significant others to take care of themselves - ask directly if family wants to be present at time of death - holistic care for dying patients - HCP must certify that patient will die within 6 months - Correct Answer-hospice care What are the 2 key premises for hospice care? - Correct Answer-1. The quality of life is just as important as the length of life 2. Those who are terminally ill should be allowed to face death with dignity & surrounded by the comfort of their families & homes - holistic comfort care - no further efforts will be made to stop the disease process or prevent the patient from dying - Correct Answer-palliative care - a "journey" that takes place over time & involves the accumulation of life experiences & understanding - an attempt to find value, meaning, & purpose in life - Correct Answer-spirituality True/False: Spirituality is important regardless of religion - Correct Answer-true spirituality is important regardless of religion What are the 5 Kubler-Ross stages of loss? - Correct Answer-1. Denial Nursing Nursing 2. Anger 3. Bargaining 4. Depression 5. Acceptance the undesired change or removal of a valued object, person, or situation - Correct Answer-loss What are the different types of loss? - Correct Answer-- actual - perceived - physical - psychological - external - environmental - loss of significant relationship - maturational - situational - internal & only identified by the person experiencing it - less obvious to the person experiencing it - Correct Answer-perceived loss - occurs during the life cycle predictably - loss of aspect of self, resulting from normal changes of growth & development - Correct Answer-maturational loss loss of a person, thing, or quality resulting from an alteration of a life situation involving changes r/t death, illness, change in body image, & environment - Correct Answer situational loss What are the four reactions to loss? - Correct Answer-- physical - emotional - cognitive - behavioral type of loss characterized by chest tightness, breathlessness, fatigue, lack of energy, & appetite change - Correct Answer-physical loss type of loss characterized by numbness, loneliness, sadness, guilt, shock, & anger - Correct Answer-emotional loss type of loss characterized by forgetfulness, inability to exercise, & disorganization - Correct Answer-cognitive loss type of loss characterized by arguing, insomnia, withdrawal, & irritability - Correct Answer-behavioral loss Nursing Nursing What does the acronym HOPE stand for in relation to spirituality? - Correct Answer-H - sources of hope O - organized religion P - personal spirituality/practices E - effects on medical care & end-of-life issues What does the acronym SPIRIT stand for in relation to spirituality? - Correct Answer-SP - spiritual/religious belief system I - integration within a special community R - ritualized practices & restrictions I - implication for medical care T - terminal events planning - evolving pattern of believing that grounds & guides/helps us make sense of the world & confront the challenges we face - represents a set of beliefs - Correct Answer-faith - dynamic process that reflects a positive orientation toward future outcomes - positive expectation & desire for future things to happen - Correct Answer-hope What documentation is the nurse responsible for after death of a patient? - Correct Answer-- date/time you noticed absence of respirations & pulse - any equipment present (i.e. ventilator) - disposition of patient's belongings - when body was transported to the morgue What are some cultural considerations that we need to think about surrounding end of life care? - Correct Answer-- openness to discussing end-of-life care options - extraordinary measures - life support - DNR/DNI orders How many stages of death are there? a) 2 b) 4 c) 6 d) 8 - Correct Answer-b) 4 stage of death where the patient begins to withdrawal from world/people; increased sleep and decreased appetite - Correct Answer-1-3 months prior to death stage of death that shows a host of physical changes that indicate the body is about to lose itself - Correct Answer-1-2 weeks prior to death Nursing Nursing stage of death that brings a o surge of energy; brings desire to eat & socialize; may become agitated and/or dehydrated - Correct Answer-days to hours prior to death stage of death dying person doesn't respond to touch/sound & can't be awakened - Correct Answer moments prior to death caring for the patient's body after death - Correct Answer-post-mortem care an order written by a physician to not attempt resuscitation when cardiac or respiratory arrest occurs - Correct Answer-DNR (do not resuscitate) Instead of writing a DNR order, some physicians may prefer to to write a/an _________ order, since it makes the patient's intentions more clear. - Correct Answer-AND (allow natural death) physical, psychological, & spiritual responses to a loss (emotional response to loss) - Correct Answer-grief What are the 4 types of grief? - Correct Answer-- uncomplicated - complicated - anticipatory - disenfranchised grief that is experienced before the loss occurs; cognitive, affective, cultural, & social reactions - Correct Answer-anticipatory grief action associated with grief; outward expression of loss 1st task - accept reality 2nd task - work through pain 3rd pain - emotionally relocate dead - Correct Answer-mourning mourning & adjustment time following a loss; form of grief with anxious feelings (insomnia, hyperactivity) - Correct Answer-bereavement What are some factors that affect grief? - Correct Answer-- age