Nurs 345 Test 1 Questions and Correct
Answers
The nurse is working to increase functional ability with a client. Which assistive
technique should be included in the plan of care? ✅trapeze bar
The sensory organs in the inner ear provide this sense of position, orientation &
movement?
Proprioceptor or kinesthetic sense
Labyrinthine sense
Visual/optic reflexes
Extensor/stretch reflexes ✅Labyrinthine sense
This informs the brain of the location of a limb or body part as a result of joint
movements, stimulating special nerve endings in muscles, tendons, & fascia?
Labyrinthine sense
Visual/optic reflexes
extensor/stress reflexes
proprioceptor/kinesthetic sense ✅Proprioceptor/kinesthetic sense
When extensor muscles are stretched beyond a certain point their stimulation causes a
reflex contraction that aids a person to reestablish erect posture?
Extensor/stretch reflexes
Visual reflexes
Labyrinthine sense ✅Extensor/stretch reflexes
What are the phases of wound healing? ✅Hemostasis
Inflammatory
Proliferation
Maturation
What is stage 2 of a pressure injury? ✅shallow open ulcer
What is stage 3 of a pressure injury? ✅tissue layers visible extending into adipose (fat)
What is stage 4 of a pressure injury? ✅muscle fibers/ bone is exposed
What is an unstageable pressure injury? ✅Obscured full-thickness skin & tissue loss
What is a deep tissue pressure injury? ✅persistent non-blanchable deep red, maroon,
or purple discoloration
What is an open system drain? ✅Penrose drain
, What are closed systems drains? ✅Jackson-pratt (small squeeze one) & Hemovac
drain
Localized pressure injury to the skin, underlying tissue, & over bony prominences are
caused by what? ✅Shearing forces & friction
Where are fats primarily digested? ✅Small intestine
What is the sedation assessment scale? ✅Used to categorize patients using pain
meds
Sleeping easy to arouse = S
Awake & alert = 1
Slightly drowsy, easily aroused = 2
Frequently drowsy, arousable, drifts off during conversation = 3
Somnolent, minimal or no response to physical stimulation = 4
Which vitamin is only found in animal foods? ✅Vitamin b12
A nurse is working with a client who is interested in losing weight and asks the nurse
why trans fats are so bad for you. What is the best response by the nurse? ✅Trans
fats lower HDL levels.
Trans fats raise LDL levels.
Trans fats raise cholesterol levels
The nurse examines the client's lab results: transferrin 220 mg/dL, hematocrit 33%,
serum creatinine 1 mg/dL, BUN 17 mg/dL. The nurse should provide which action?
✅increase foods rich in iron
The nurse is assessing a client who has dysphagia. When sitting with the client to assist
with feeding, the client waves the food away and turns the face away from the nurse.
What action(s) will the nurse take? Select all that apply.
Check the client's bowel record to determine the last bowel movement.
Use a visual scale to assess the client's current pain level.
Allow the client to attempt to eat the food independently.
Ask the client if he or she is experiencing nausea.
Review the client's most recent sleep log. ✅Check the client's bowel record to
determine the last bowel movement
Use a visual scale to assess the client's current pain level
Ask the client if he/she is experiencing nausea
Review the client's most recent sleep log
Which method of feeding would a nurse normally provide if a client can attempt eating
regular meals during the day and is prepared to ambulate and resume activities?
Continuous feeding
Answers
The nurse is working to increase functional ability with a client. Which assistive
technique should be included in the plan of care? ✅trapeze bar
The sensory organs in the inner ear provide this sense of position, orientation &
movement?
Proprioceptor or kinesthetic sense
Labyrinthine sense
Visual/optic reflexes
Extensor/stretch reflexes ✅Labyrinthine sense
This informs the brain of the location of a limb or body part as a result of joint
movements, stimulating special nerve endings in muscles, tendons, & fascia?
Labyrinthine sense
Visual/optic reflexes
extensor/stress reflexes
proprioceptor/kinesthetic sense ✅Proprioceptor/kinesthetic sense
When extensor muscles are stretched beyond a certain point their stimulation causes a
reflex contraction that aids a person to reestablish erect posture?
Extensor/stretch reflexes
Visual reflexes
Labyrinthine sense ✅Extensor/stretch reflexes
What are the phases of wound healing? ✅Hemostasis
Inflammatory
Proliferation
Maturation
What is stage 2 of a pressure injury? ✅shallow open ulcer
What is stage 3 of a pressure injury? ✅tissue layers visible extending into adipose (fat)
What is stage 4 of a pressure injury? ✅muscle fibers/ bone is exposed
What is an unstageable pressure injury? ✅Obscured full-thickness skin & tissue loss
What is a deep tissue pressure injury? ✅persistent non-blanchable deep red, maroon,
or purple discoloration
What is an open system drain? ✅Penrose drain
, What are closed systems drains? ✅Jackson-pratt (small squeeze one) & Hemovac
drain
Localized pressure injury to the skin, underlying tissue, & over bony prominences are
caused by what? ✅Shearing forces & friction
Where are fats primarily digested? ✅Small intestine
What is the sedation assessment scale? ✅Used to categorize patients using pain
meds
Sleeping easy to arouse = S
Awake & alert = 1
Slightly drowsy, easily aroused = 2
Frequently drowsy, arousable, drifts off during conversation = 3
Somnolent, minimal or no response to physical stimulation = 4
Which vitamin is only found in animal foods? ✅Vitamin b12
A nurse is working with a client who is interested in losing weight and asks the nurse
why trans fats are so bad for you. What is the best response by the nurse? ✅Trans
fats lower HDL levels.
Trans fats raise LDL levels.
Trans fats raise cholesterol levels
The nurse examines the client's lab results: transferrin 220 mg/dL, hematocrit 33%,
serum creatinine 1 mg/dL, BUN 17 mg/dL. The nurse should provide which action?
✅increase foods rich in iron
The nurse is assessing a client who has dysphagia. When sitting with the client to assist
with feeding, the client waves the food away and turns the face away from the nurse.
What action(s) will the nurse take? Select all that apply.
Check the client's bowel record to determine the last bowel movement.
Use a visual scale to assess the client's current pain level.
Allow the client to attempt to eat the food independently.
Ask the client if he or she is experiencing nausea.
Review the client's most recent sleep log. ✅Check the client's bowel record to
determine the last bowel movement
Use a visual scale to assess the client's current pain level
Ask the client if he/she is experiencing nausea
Review the client's most recent sleep log
Which method of feeding would a nurse normally provide if a client can attempt eating
regular meals during the day and is prepared to ambulate and resume activities?
Continuous feeding
