Unit 5

A nurse is caring for a patient with a stroke that has impacted her ability to see. Which area of the brain was likely impacted by the stroke that is responsible for visual function?

The family of a patient who was in a motor vehicle accident tells you he "just isn't the same person before the crash." You know this is likely because the injury to what area of his brain?

The nurse educating the family of a patient in the ICU about the pt's cognitive status, including her current problem of delirium. Which statement by the family indicates a need for further education?

The nurse is caring for patient with depression. Which statement by the patient indicates a need for further education?

Nurse notices her 50 year old patient is holding their lunch menu at arms length while trying to read their choices. This is an indication of?

An appropriate goal for the patient with the diagnosis of acute confusion is?

An appropriate goal for a patient with a diagnosis of social isolation is?

The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?

The nurse is delegating care to a unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?

The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?

The nurse is completing her assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply)

You are giving education to the family of a patient being discharged with dementia. Which statement by the family indicates a good level of understanding of dementia? (Select all that apply)

The nurse is caring for patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply)

The nurse is performing a health history to determine the patient's cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply)

The nurse is performing a health history to determine the patient's sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply)

The nurse is caring for a diabetic patient who has a long history of poor glucose control. For what complications is the patient at risk for? (Select all that apply)

The nurse is caring for patient who is hospitalized with cognitive impairment. The following interventions will assist the patient in orientation? (Select all that apply)

The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply)

The nurse is preparing discharge instructions for a patient with tactile alterations in his legs. Which instructions should be included? (Select all that apply)

The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions should be included? (Select all that apply)

The nurse is implementing generalized fall precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?

The nurse is performing range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do?

The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis 'Impaired Mobility'?

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding of these exercises?

Which explanation by the nurse best describes active assistive range of motion?

The nurse delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?

The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk? (Select all that apply)

The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities??

The nurse identifies that knee-high SCD sleeves are correctly placed on the patient when which conditions are met? (Select all that apply)

The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply)

A patient complains of shoulder pain during a gallbladder attack. How does the nurse document this pain?

The patient who had surgery to remove part of the intestines is complaining of pain. What type of pain is the patient experiencing?

Which symptom does the nurse recognize as a physiologic response to acute pain?

The nurse is checking on the patient after administering pain medications 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective?

The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. The nurse recognizes which type of pain is this patient experiencing?

The nurse identifies which patient to be best suited for PCA analgesia?

What is the priority nursing assessment for a patient who is receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?

When assessing the patient for pain, which factors should the nurse consider? (Select all that apply)

Which statement best describes the dosage of prescribed pain medication that a nurse should administer given pharmacologic treatment considerations?

The endocrine system releases excessive hormones during episodes of acute pain. The nurse should monitor patient's experiencing acute pain for which potential problems?

Patient who had a below the knee amputation 3 days ago complains of pain from the amputated extremity. Which response by the nurse best explains what the patient is experiencing?

An uncooperative 70 year old male with right-sided paralysis from a recent CVA has to be transferred from the bed to wheelchair. Which action indicates the best method to transfer this patient?

After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches?

Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury?

What nursing intervention would be most effective in precenting flaccidity in a hospitalized patient?

Which nursing diagnosis is a top priority for a patient who is one day status post hip replacement?

The nurse is assessing the patient's ability to hear and knows which is the correct procedure for the doing this?

The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions will the nurse include? (Select all that apply)

The nurse is caring for a patient recovering from knee replacement surgery. The patient complains of severe pain in the knee receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously. What is the nurse's best reaction?

What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system?

The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware?

The nurse identifies which instruction to be appropriate to delegate to the UAP?

The nurse is preparing to reposition the patient in bed. What is the first step in the process?

The nurse correctly teachers the patient to rise from a chair using crutches when which intervention is used?

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of which condition? (Select all that apply)

The nurse knows which items are included in the documentation for a patient on fall precautions? (Select all that apply)

The nurse knows which findings indicate orthostatic hypotension

The nurse administered 100 mcg sublingual fentanyl spray at 10:00 am to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained?

Health care provider orders 1,500 mL of 0.9% saline to be infused over seven hours. The drop factor is 15 drops/mL. What should the hourly rate on the infusion pump?

Health care provider orders 1,500 mL of 0.9% saline to be infused over seven hours. The drop factor is 15 drops/mL. How many drips per minute should the nurse count?