NUR 215 Exam 2
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NUR 215 Exam 2
It is most important for the nurse to understand the various ways in which pain
is classified so that he or she can
A. Document the client’s pain using accurate terms.
B. Be clear in communication with the physician.
C. Develop an effective pain management plan.
D. Educate the client thoroughly.
C: Develop an effective pain management plan
Different modalities are used in the treatment/ management of pain and are often
based on how the pain is classified (e.g., acute versus chronic).
The nurse is assessing the confused client. In trying to determine the client’s
level of pain, the nurse should
A. Be aware that confused clients do not feel as much pain due to their
confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client’s family how much pain the client normally has.
D. Use only pain scales that feature numbers or “faces” the client can point to.
B. Observe the client carefully for changes in behavior or vital signs.
The nurse should observe the confused client for nonverbal cues to pain.
Mr. Zenobia’s chronic cancer pain has recently increased, and he asks the
home health nurse what can be done. In relation to his long-acting opioid,
which is an appropriate response by the nurse?
A. “If you take more opioid, it will not change your pain relief.“
B. “I’ll call the primary care provider and ask for an increased dose.”
C. “The amount you are taking now is all I can give you.”
D. “I’m worried if we increase your dose that you will stop breathing.”
B. "I'll call the primary care provider and ask for an increased dose."
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There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a
tolerance to the effects, which often necessitates an increase in the dose.
To maintain proper posture, it is important to
A. Sleep on the softest mattress possible.
B. Avoid arching shoulders forward when sitting.
C. Keep your knees locked when standing upright.
D. Keep your stomach muscles relaxed to prevent back spasms.
B. Avoid arching shoulders forward when sitting.
Arching shoulders forward when sitting alters the curvature of the spine and
contributes to poor body alignment.
Of the following interventions for the client who is immobile, the nurse will
give priority to
A. Encouraging a diet high in fiber and extra fluids
B. Administering the medication for sleep as needed
C. Having the client use the incentive spirometer q 2 hrs
D. Massaging the client’s legs every hour
C. Having the client use the incentive spirometer q 2 hrs
Use of the incentive spirometer helps to prevent atelectasis, which improves
oxygenation—a priority need.
Identify the true statement about devices used when assisting clients to
ambulate.
A. The client should stand a foot back from the back legs of a walker.
B. A cane should be used by the client to support the weakest side of the
body.
C. A transfer belt should be placed around the client’s chest for maximum lift.
D. Each crutch-walking gait begins with the client in the tripod position.
D. Each crutch-walking gait begins with the client in the tripod position.
The tripod position is the basic crutch standing position from which the client then
moves forward.
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A name-brand ice cream contains the following nutrition information for each
serving: 30 g carbohydrates, 19 g fat, 5 g protein. The total number of calories
in a serving would be
A. 366
B. 311
C. 435
D. 176
B. 311
CHO = 4 cal per gram = 120 cal
Fat = 9 cal per gram = 171 cal
Protein = 4 cal per gram = 20 cal
Total: 311 cal
Identify the client with the greatest risk for developing protein-calorie
malnutrition.
A. A client who has multiple sclerosis and is in a wheelchair
B. A client weighing 300 lb who has entered the hospital for cardiac bypass
surgery
C. A client with a broken arm and femur from trauma who is running a fever of
101.5°F (38.6°C)
D. A client who is of Native American heritage
C. A client with a broken arm and femur from trauma who is running a fever of
101.5°F (38.6°C)
This client would have the greatest increase in metabolic demand for
"energy"/nutrients and runs the greatest risk for not having those energy demands
met.
The nurse knows the lab result that is the best indicator of a client’s nutritional
status is the serum albumin.
A. True
B. False
B. False
The latest research shows that prealbumin has a shorter half-life than albumin and is
a better indicator of protein stores (and acute changes in those stores).