During an admission assessment, the nurse collects objective and subjective data. What is an example objective data? Select one a The patient complains of auditory hallucinations. b. The patient states, I hear voices in my head c. The patient complains of feeling depressed. d. The patient is pacing back and forth while chanting
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- 1) The nurse has administered an opioid analgesic to a client. Which interventions should the nurse implement? Select all that applyA. Discuss with the physician starting the client on a stool softener.B. Teach the client about rating the pain on a numeric pain scale.C. Inform the client to rise quickly from a supine position.D. Tell the client to call for assistance when getting out of bed. 2). Mrs. Lee has been taking ibuprofen for the last 2 months. She has noticed both her knees are occasionally red and warm when she touches them. She has observed that besides her knee pain, the joints in her hands have been red with some swelling. The physician diagnoses Mrs. Lee with rheumatoid arthritis and gout. He starts her on allopurinol 100mg PO every day and celecoxib 100mg PO BID for pain. In teaching Mrs. Lee about her new medication regimen: You describe to Mrs. Lee how allopurinol will help in the management of her joint pain. What is your best explanation?A. “Allopurinol reduces the…A nurse is preparing a patient for a cesarean section and teachesher the effects of the regional anesthesia she will be receiving.Which effects would the nurse expect? Select all that apply.a. Loss of consciousnessb. Relaxation of skeletal musclesc. Reduction or loss of reflex actiond. Localized loss of sensatione. Prolonged pain relief after other anesthesia wears offf. Infiltrates the underlying tissues in an operative areaA nurse formulates the following diagnosis for an elderlypatient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the fol-lowing nursing interventions would the nurse perform related to 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.e. Encourage patient to engage in some type of physicalactivity. f. Assess medication for side effects of sleep pattern distur-bances.
- A client who is recovering from an appendectomy is receiving narcotics, earlier the nurse witnessed the client’s family pushing the pain pump, what should the nurse implement? A. Check client’s level of consciousness B. Instruct the family not to push the button C. Stop the client’s basal infusion D. Administer a narcotic reversal medicationA nurse is teaching a patient with a sleep disorder how tokeep a sleep diary. Which data would the nurse have thepatient document? Select all that apply.a. Daily mental activitiesb. Daily physical activitiesc. Morning and evening body temperatured. Daily measurement of fluid intake and outpute. Presence of anxiety or worries affecting sleepf. Morning and evening blood pressure readingsDuring an interaction with a patient diagnosed with epilepsy,a nurse notes that the patient is silent after she communicatesthe plan of care. What would be appropriate nurse responsesin this situation? Select all that apply.a. Fill the silence with lighter conversation directed at thepatient. b. Use the time to perform the care that is needed uninter-rupted. c. Discuss the silence with the patient to ascertain its mean-ing. d. Allow the patient time to think and explore inner thoughts.e. Determine if the patient’s culture requires pauses betweenconversation. f. Arrange for a counselor to help the patient cope with emo-tional issues.
- When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly1). Due to the client’s diagnosis of low back pain, cyclobenzaprine is prescribed. Which instructionsshould the nurse teach the client? Select all that applyA. Take the medication just before leaving home for work each day.B. Drink a full glass of water with each dose of medication.C. The medication can cause drowsiness that will make driving unsafe.D. Divide the dose of medication between early morning and bedtime.E. Encourage the client to change positions slowly. 2).The nurse working in the postanesthesia care unit (PACU) recovering a male client after anexploratory laparotomy administers the prescribed hydromorphone intravenously. Five minuteslater the nurse assess the client’s respirations at 8 breaths per minute. Which interventionshould the nurse implement first?A. Ask the anesthesiologist to come and assess the client.B. Administer naloxone intravenously.C. Re-assess the client’s respiratory status in 20 minutes.D. Use an ambu bag and ventilate the client. 3).An adolescent…Minerva is given a propranolol (Inderal) 40 mg bid. What is the most important instruction the nurse should give to this client?a. Take this medication on an empty stomach, as food interferes with its absorption.b. Do not stop taking this medication abruptly; the dosage must be decreased gradually if it isdiscontinued.c. If the client experiences any disturbances in hearing, the client should notify the health care providerimmediately.d. The client may become very sleepy while taking this medication; do not drive.Is letter b the correct answer why or why not? Also explain why the other options are not the right answer (a,c and d)
- An older client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit? A. Arrange food on the plate in clockwise order B. Apply bilateral eye patches while sleeping C. Verbally identify self when entering the room D. Use a white board to communicate ideasns n vity) 1. When discussing palliative care with a patient, what would you say are the goals? (Mark all that apply.) a. Improvement in the quality of life b. Providing bereavement support C. Management of family values d. Relieving suffering e. Communication among family members ANSWER: RATIONALE: 2. You are assessing an older adult patient for a closed head injury after a motor vehicle accident. What reflex would you assess for? The pig reflex b. The grasp reflex c. The snout reflex d. The spinal reflex ANSWER: RATIONALE: а. 3. A 75-year-old female patient tells you that she is sexually active but that it causes her pain when she has intercourse. What would you suggest to alleviate this pain? Warm baths a. b. Only use a side-lying position Cold application d. Have sex in the morning c. ANSWER: RATIONALE: 4. What would be important to assess when detecting alcohol use disorders in older adults? a. Increasing appetite b. Impaired proprioception Blood sugar control problems d.…The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what dlients with this disorder typically see, Although all of the following measures might be useful n reducing the visual disability of a client with aduls macular degeneration (AMD), which measure should the nurse teach the client primarily as a safery precaution? 1. Wear a patch over one eye. 2. Place personal irems on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4.Turn the head from side o side when walking i o ' ]