NU120 WEEK 3

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NU120 WEEK 3
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2014-01-05 18:12:39
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NU120 WEEK 3
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  1. THE NURSE IS GATHERING A SLEEP HISTORY FROM A PATIENT WHO IS BEING EVALUATED FOR OBSTRUCTIVE SLEEP APNEA.  WHICH COMMON SYMPTOMS DOES THE PATIENT MOST LIKELY REPORT?  (SELECT ALL THAT APPLY)
    1.  HEADACHE
    2.  EARLY WAKENING
    3.  EXCESSIVE DAYTIME SLEEPINESS
    4.  DIFFICULTY FALLING ASLEEP
    5.  SNORING
    • 1.  HEADACHE
    • 3.  EXCESSIVE DAYTIME SLEEPINESS
    • 5.  SNORING
  2. THE NURSE INCORPORATES WHICH PRIORITY NURSING INTERVENTION INTO A PLAN OF CARE TO PROMOTE SLEEP FOR A HOSPITALIZED PATIENT?
    1.  HAVE PATIENT FOLLOW HOSPITAL ROUTINES
    2.  AVOID AWAKENING PATIENT FOR NONESSENTIAL TASKS
    3.  GIVE PRESCRIBED SLEEPING MEDICATIONS AT DINNER
    4.  TURN TELEVISION ON LOW TO LATE NIGHT PROGRAMMING
    2.  AVOID AWAKENING PATIENT FOR NONESSENTIAL TASKS
  3. OLDER ADULTS ARE CAUTIONED ABOUT THE LONG TERM USE OF SEDATIVES AND HYPNOTICS BECAUSE THESE MEDICATIONS CAN:
    1.  CAUSE HEADACHES AND NAUSEA
    2.  BE EXPENSIVE AND DIFFICULT TO OBTAIN
    3.  CAUSE SEVERE DEPRESSION AND ANXIETY
    4.  LEAD TO SLEEP DISRUPTION
    4.  LEAD TO SLEEP DISRUPTION
  4. THE NURSE IS PROVIDING HEALTH TEACHING FOR A PATIENT USING HERBAL COMPOUNDS SUCH AS MELATONIN FOR SLEEP.  WHICH POINTS NEED TO BE INCLUDED?  (SELECT ALL THAT APPLY)
    1.  CAN CAUSE URINARY RETENTION
    2.  SHOULD NOT BE USED INDEFINITELY
    3.  MAY CAUSE DIARRHEA AND ANXIETY
    4.  MAY INTERFERE WITH PRESCRIBED MEDICATIONS
    5.  CAN LEAD TO FURTHER SLEEP PROBLEMS OVER TIME
    6.  ARE NOT REGULATED BY THE US FOOD AND DRUG ADMINISTRATION
    • 2.  SHOULD NOT BE USED INDEFINITELY
    • 4.  MAY INTERFERE WITH PRESCRIBED MEDICATIONS
    • 6.  ARE NOT REGULATED BY THE US FOOD AND DRUG ADMINISTRATION
  5. THE PATIENT REPORTS VIVID DREAMING TO THE NURSE.  THROUGH UNDERSTANDING OF THE SLEEP CYCLE, THE NURSE RECOGNIZES THAT VIVID DREAMING OCCURS DURING WHICH SLEEP PHASE?
    1.  REM SLEEP
    2.  STAGE 1 NREM SLEEP
    3.  STAGE 4 NREM SLEEP
    4.  TRANSITION PERIOD FROM NREM TO REM SLEEP
    1.  REM SLEEP
  6. THE NURSE TEACHES A PATIENT TAKING A BENZODIAZEPINE THAT THIS GROUP OF MEDICATIONS CAUSES WHICH SYMPTOM OF A SLEEP PROBLEM?
    1.  NOCTURIA
    2.  HYPERACTIVITY
    3.  GROGGINESS AND FEELING HUNG OVER
    4.  INCREASED SLEEP TIME
    3.  GROGGINESS AND FEELING HUNG OVER
  7. WHICH INTERVENTION IS APPROPRIATE TO INCLUDE ON A CARE PLAN FOR IMPROVING SLEEP IN THE OLDER ADULT?
    1.  DECREASE FLUIDS 2 TO 4 HOURS BEFORE SLEEP
    2.  EXERCISE IN THE EVENING TO INCREASE FATIGUE
    3.  ALLOW THE PATIENT TO SLEEP AS LATE AS POSSIBLE
    4.  TAKE A NAP DURING THE DAY TO MAKE UP FOR LOST SLEEP
    1.  DECREASE FLUIDS 2 TO 4 HOURS BEFORE SLEEP
  8. WHICH STATEMENT MADE BY A MOTHER BEING DISCHARGED TO HOME WITH HER NEWBORN INFANT INDICATES A NEED FOR FURTHER TEACHING
    1.  i WON'T PUT THE BABY TO BED WITH A BOTTLE
    2.  FOR THE FIRST FEW WEEKS WE'RE PUTTING THE CRADLE IN OUR ROOM
    3. MY GRANDMOTHER TOLD ME THAT BABIES SLEEP BETTER ON THEIR STOMACHS
    4.  I KNOW I'LL HAVE TO GET UP DURING THE NIGHT TO FEED THE BABY WHEN HE WAKES UP
    3. MY GRANDMOTHER TOLD ME THAT BABIES SLEEP BETTER ON THEIR STOMACHS
  9. THE NURSE IS DEVELOPING A PLAN OF CARE FOR A PATIENT EXPERIENCING NARCOLEPSY.  WHICH INTERVENTION IS APPROPRIATE TO INCLUDE ON THE PLAN?
    1.  INSTRUCT THE PATIENT TO INCREASE CARBOHYDRATES IN THE DIET
    2.  HAVE PATIENT LIMIT FLUID INTAKE 2 HOURS BEFORE BEDTIME
    3.  PRESERVE ENERGY BY LIMITING EXERCISE TO MORNING HOURS
    4.  ENCOURAGE PATIENT TO TAKE ONE OR TWO 20 MINUTE NAPS DURING THE DAY
    4.  ENCOURAGE PATIENT TO TAKE ONE OR TWO 20 MINUTE NAPS DURING THE DAY
  10. WHICH NURSING MEASURE BEST PROMOTES SLEEP IN A SCHOOL AGE CHILD
    1.  ENCOURAGE EVENING EXERCISE
    2.  OFFER A GLASS OF HOT CHOCOLATE BEFORE BEDTIME
    3.  MAKE SURE THAT THE ROOM IS DARK AND QUIET
    4.  USE QUIET ACTIVITIES CONSISTENTLY BEFORE BEDTIME
    4.  USE QUIET ACTIVITIES CONSISTENTLY BEFORE BEDTIME
  11. WHICH ACTION BY THE NURSING ASSISTANT AT BEDTIME REQUIRES THE NURSE TO INTERVENE?
    1.  GIVING THE PATIENT A BACK RUB
    2.  TURNING ON QUIET MUSIC
    3.  DIMMING THE LIGHTS IN THE PATIENT'S ROOM
    4.  GIVING A PATIENT A CUP OF COFFEE
    4.  GIVING A PATIENT A CUP OF COFFEE
  12. WHICH STATEMENT MADE BY THE PATIENT INDICATES A NEED FOR FURTHER TEACHING ON SLEEP HYGIENE
    1.  I'M GOING TO DO MY EXERCISES BEFORE I EAT DINNER
    2.  I'LL HAVE A GLASS OF WINE AT BEDTIME TO RELAX
    3.  I SET MY ALARM TO GET UP AT THE SAME TIME EVERY MORNING
    4.  I MOVED MY COMPUTER TO THE DEN TO DO MY WORK
    2.  I'LL HAVE A GLASS OF WINE AT BEDTIME TO RELAX
  13. WHICH STATEMENT MADE BY AN OLDER ADULT BEST DEMONSTRATES UNDERSTANDING OF TAKING A SLEEP MEDICATION
    1.  I'LL TAKE THE SLEEP MEDICINE FOR 4 TO 5 WEEKS UNTIL MY SLEEP PROBLEMS DISAPPEAR
    2.  SLEEP MEDICINES WON'T CAUSE ANY SLEEP PROBLEMS ONCE I STOP TAKING THEM
    3.  I'LL TALK TO MY HEALTH CARE PROVIDER BEFORE I USE AN OVER THE COUNTER SLEEP MEDICATION
    4.  I'LL CONTACT MY HEALTH CARE PROVIDER IF I FEEL EXTREME SLEEPY IN THE MORNINGS
    3.  I'LL TALK TO MY HEALTH CARE PROVIDER BEFORE I USE AN OVER THE COUNTER SLEEP MEDICATION
  14. THE SCHOOL NURSE IS TEACHING HEALTH PROMOTING BEHAVIORS THAT IMPROVE SLEEP TO A GROUP OF HIGH SCHOOL STUDENTS.  WHICH POINTS SHOULD BE INCLUDED IN THE EDUCATION?  (SELECT ALL)
    1.  DO NOT STUDY IN YOUR BED
    2.  GO TO SLEEP EACH NIGHT WHENEVER YOU FEEL TIRED
    3.  TURN OFF YOUR CELL PHONE AT BEDTIME
    4.  AVOID DRINKING COFFEE OR SODA BEFORE BEDTIME
    5.  TURN ON THE TELEVISION TO HELP YOU FALL ASLEEP
    • 1.  DO NOT STUDY IN YOUR BED
    • 3.  TURN OFF YOUR CELL PHONE AT BEDTIME
    • 4.  AVOID DRINKING COFFEE OR SODA BEFORE BEDTIME
  15. THE NURSE IS TAKING A SLEEP HISTORY FROM A PATIENT.  WHICH STATEMENT MADE BY THE PATIENT NEEDS FURTHER FOLLOW UP?
    1.  I ALWAYS FEEL TIRED WHEN I WAKE UP IN THE MORNING
    2.  I GO TO BED AT THE SAME TIME EACH NIGHT
    3.  IT TAKES ME ABOUT 15 MINUTES TO FALL ASLEEP
    4.  SOMETIMES I HAVE TO GET UP DURING THE NIGHT TO URINATE
    1.  I ALWAYS FEEL TIRED WHEN I WAKE UP IN THE MORNING
  16. WHICH OF THE FOLLOWING SIGNS OR SYMPTOMS IN AN OPIOD-NAIVE PATIENT IS OF GREATEST CONCERN TO THE NURSE WHEN ASSESSING THE PATIENT 1 HOUR AFTER ADMINISTERING AN OPIOD?
    1.  OXYGEN SATURATION OF 95%
    2.  DIFFICULTY AROUSING THE PATIENT
    3.  RESPIRATORY RATE OF 10 BREATHS/MIN
    4.  PAIN INTENSITY RATING OF 5 ON A SCALE OF 0 TO 10
    2.  DIFFICULTY AROUSING THE PATIENT
  17. A HEALTH CARE PROVIDER WRITES THE FOLLOWING ORDER FOR AN OPIOID NAIVE PATIENT WHO RETURNED FROM THE OPERATING ROOM FOLLOWING A TOTAL HIP REPLACEMENT.  "FENTANYL PATCH 100 MCG, CHANGE EVERY 3 DAYS"  BASED ON THIS ORDER, THE NURSE TAKES THE FOLLOWING ACTION:
    1.  CALLS THE HEALTH CARE PROVIDER, AND QUESTIONS THE ORDER
    2.  APPLIES THE PATCH THE THIRD POSTOPERATIVE DAY
    3.  APPLIES THE PATCH AS SOON AS THE PATIENT REPORTS PAIN
    4.  PLACES THE PATCH AS CLOSE TO THE HIP DRESSING AS POSSIBLE
    1.  CALLS THE HEALTH CARE PROVIDER, AND QUESTIONS THE ORDER
  18. A PATIENT IS BEING DISCHARGED HOME ON AN AROUND THE CLOCK (ATC) OPIOID FOR CHRONIC BACK PAIN.  BECAUSE OF THIS ORDER, THE NURSE ANTICIPATES AN ORDER FOR WHICH CLASS OF MEDICATION
    1.  STOOL SOFTENER
    2.  STIMULANT LAXATIVE
    3.  H2 RECEPTOR BLOCKER
    4.  PROTON PUMP INHIBITOR
    2.  STIMULANT LAXATIVE
  19. A NEW MEDICAL RESIDENT WRITES AN ORDER FOR OXYCONTIN SR 10 MG PO Q12 HOURS PRN.  WHICH PART OF THE ORDER DOES THE NURSE QUESTION
    1.  THE DRUG
    2.  THE TIME INTERVAL
    3.  THE DOSE
    4.  THE ROUTE
    2.  THE TIME INTERVAL
  20. THE NURSE NOTICES THAT A PATIENT HAS RECEIVED OXYCODONE/ACETAMINOPHEN (PERCOCET) (5/325), TWO TABLETS PO EVERY 3 HOURS FOR THE PAST 3 DAYS.  WHAT CONCERNS THE NURSE THE MOST
    1.  THE PATIENT'S LEVEL OF PAIN
    2.  THE POTENTIAL FOR ADDICTION
    3.  THE AMOUNT OF DAILY ACETAMINOPHEN
    4.  THE RISK FOR GASTROINTESTINAL BLEEDING
    3.  THE AMOUNT OF DAILY ACETAMINOPHEN
  21. A PATIENT WITH CHRONIC LOW BACK PAIN WHO TOOK AN OPIOID AROUND THE CLOCK (ATC) FOR THE PAST YEAR DECIDED TO ABRUPTLY STOP THE MEDICATION FOR FEAR OF ADDICTION.  HE IS NOW EXPERIENCING SHAKING, CHILLS, ABDOMINAL CRAMPS, AND JOINT PAIN.  THE NURSE RECOGNIZES THAT THIS PATIENT IS EXPERIENCING SYMPTOMS OF:
    1.  ADDICTION
    2.  TOLERANCE
    3.  PSEUDO ADDICTION
    4.  PHYSICAL DEPENDENCE
    4.  PHYSICAL DEPENDENCE
  22. AFTER HAVING RECEIVED 0.2 MG OF NALOXONE (NARCAN) INTRAVENOUS PUSH (IVP), A PATIENT'S RESPIRATORY RATE AND DEPTH ARE WITHIN NORMAL LIMITS.  THE NURSE NOW PLANS TO IMPLEMENT THE FOLLOWING ACTION
    1.  DISCONTINUE ALL ORDERED OPIOIDS
    2.  CLOSE THE ROOM DOOR TO ALLOW THE PATIENT TO RECOVER
    3.  ADMINISTER THE REMAINING NALOXONE OVER 4 MINUTES
    4.  ASSESS PATIENT'S VITAL SIGNS EVERY 15 MINUTES FOR 2 HOURS
    4.  ASSESS PATIENT'S VITAL SIGNS EVERY 15 MINUTES FOR 2 HOURS
  23. WHICH ONE OF THE FOLLOWING INSTRUCTIONS IS CRUCIAL FOR THE NURSE TO GIVE TO BOTH FAMILY MEMBERS AND THE PATIENT WHO IS ABOUT TO BE STARTED ON A PATIENT CONTROLLED ANALGESIA (PCA) OF MORPHINE
    1.  ONLY THE PATIENT SHOULD PUSH THE BUTTON
    2.  DO NOT USE THE PCA UNTIL THE PAIN IS SEVER
    3.  THE PCA PREVENTS OVERDOSES FROM OCCURRING
    4.  NOTIFY THE NURSE WHEN THE BUTTON IS PUSHED
    1.  ONLY THE PATIENT SHOULD PUSH THE BUTTON
  24. A PAITENT WITH A HISTORY OF A STOKE THAT LEFT HER CONFUSED AND UNABLE TO COMMUNICATE RETURNS FROM INTERVENTIONAL RADIOLOGY FOLLOWING PLACEMENT OF A GASTRONOMY TUBE.  THE HEALTH CARE PROVIDER'S ORDER READS AS FOLLOWS:  "VICODIN 1 TAB, PER TUBE, Q4 HOURS, PRN"  WHICH ACTION BY THE NURSE IS MOST APPROPRIATE
    1.  NO ACTION IS REQUIRED BY THE NURSE BECAUSE THE ORDER IS APPROPRIATE
    2.  REQUEST TO HAVE THE ORDERED CHANGED TO ATC FOR THE FIRST 48 HOURS
    3.  ASK FOR A CHANGE OF MEDICATION TO MEPERIDINE (DEMEROL) 50 MG IVP, Q3 HOURS, PRN
    4.  BEGIN THE VICODIN WHEN THE PATIENT SHOWS NONVERBAL SYMPTOMS OF PAIN
    2.  REQUEST TO HAVE THE ORDERED CHANGED TO ATC FOR THE FIRST 48 HOURS
  25. A PATIENT RETURNING TO THE NURSING UNIT AFTER KNEE SURGERY IS VERBALIZING PAIN AT THE SURGICAL SITE.  THE NURSE'S FIRST ACTION IS TO:
    1.  CALL THE PATIENT'S HEALTH CARE PROVIDER
    2.  ADMINISTER PAIN MEDICATION AS ORDERED
    3.  CHECK THE PATIENT'S VITAL SIGNS
    4.  ASSESS THE CHARACTERISTICS OF THE PAIN
    4.  ASSESS THE CHARACTERISTICS OF THE PAIN
  26. THE PATIENT RATES HIS PAIN AS A 6 ON A SCALE OF 0 TO 10, WITH 0 BEING NO PAIN AND 10 BEING THE WORST PAIN.  THE PATIENT'S WIFE SAYS THAT HE CAN'T BE IN THAT MUCH PAIN SINCE HE HAS BEEN SLEEPING FOR 30 MINUTES.  WHICH IS THE MOST ACCURATE RESOURCE FOR ASSESSING THE PAIN
    1.  THE PATIENT'S WIFE IS THE BEST RESOURCE FOR DETERMINING THE LEVEL OF PAIN SINCE SHE HAS BEEN WITH HIM CONTINUALLY FOR THE ENTIRE DAY
    2.  THE PATIENT'S REPORT OF PAIN IS THE BEST METHOD FOR ASSESSING THE PAIN
    3.  THE PATIENT'S HEALTH CARE PROVIDER HAS THE BEST KNOWLEDGE OF THE LEVEL OF PAIN THAT THE PATIENT THAT SHOULD BE EXPERIENCING
    4.  THE NURSE IS THE MOST EXPERIENCED AT ASSESSING PAIN.
    2.  THE PATIENT'S REPORT OF PAIN IS THE BEST METHOD FOR ASSESSING THE PAIN
  27. WHEN USING ICE MASSAGE FOR PAIN RELIEF, WHICH OF THE FOLLOWING ARE CORRECT? (SELECT ALL THAT APPLY)
    1.  APPLY ICE USING FIRM PRESSURE OVER SKIN
    2.  APPLY ICE UNTIL NUMBNESS OCCURS AND REMOVE THE ICE FOR 5 TO 10 MINUTES
    3.  APPLY ICE UNTIL NUMBMESS OCCURS AND DISCONTINUE APPLICATION
    4.  APPLY ICE FOR NO LONGER THAN 10 MINUTES
    • 1.  APPLY ICE USING FIRM PRESSURE OVER SKIN
    • 2.  APPLY ICE UNTIL NUMBNESS OCCURS AND REMOVE THE ICE FOR 5 TO 10 MINUTES
  28. WHEN TEACHING A PAITIENT ABOUT TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS), WHICH INFORMATION DO YOU INCLUDE?
    1. TENS WORKS BY CAUSING DISTRACTION
    2.  TENS THERAPY DOES NOT REQUIRE A HEALTH CARE PROVIDER'S ORDER
    3.  TENS REQUIRES AN ELECTRICAL SOURCE FOR USE
    4.  TENS ELECTRODES ARE APPLIED NEAR OR DIRECTLY ON THE SITE OF PAIN
    4.  TENS ELECTRODES ARE APPLIED NEAR OR DIRECTLY ON THE SITE OF PAIN
  29. WHILE CARING FOR A PATIENT WITH CANCER PAIN, THE NURSE KNOWS THAT THE WORLD HEALTH ORGANIZATION (WHO) ANALGESIC LADDER RECOMMENDS:
    1.  TRANSITIONING USE OF ADJUVANTS WITH NONSTEROIDAL ANTINFLAMMATORY DRUGS (NSAIDS) TO OPIOIDS
    2.  USING ACETAMINOPHEN FOR REFRACTORY PAIN
    3.  LIMITING THE USE OF OPIOIDS BECAUSE OF THE LIKELIHOOD OF SIDE EFFECTS.
    4.  AVOIDING TOTAL SEDATION, REGARDLESS OF HOW SEVER THE PAIN IS
    1.  TRANSITIONING USE OF ADJUVANTS WITH NONSTEROIDAL ANTINFLAMMATORY DRUGS (NSAIDS) TO OPIOIDS
  30. A POSTOPERATIVE PATIENT IS CURRENTLY ASLEEP.  THEREFORE THE NURSE KNOWS THAT 
    1.  THE SEDATIVE ADMINISTERED MAY HAVE HELPED HIM SLEEP, BUT ASSESSMENT OF PAIN IS STILL NEEDED
    2.  THE INTRAVENOUS (IV) PAIN MEDICATION IS EFFECTIVELY RELIEVING HIS PAIN
    3.  PAIN ASSESSMENT IS NOT NECESSARY
    4.  THE PATIENT CAN BE SWITCHED TO THE SAME AMOUNT OF MEDICATION BY THE ORAL ROUTE
    1.  THE SEDATIVE ADMINISTERED MAY HAVE HELPED HIM SLEEP, BUT ASSESSMENT OF PAIN IS STILL NEEDED
  31. A PATIENT HAS BEEN ON CONTACT ISOLATION FOR 4 DAYS BECAUSE OF A GASTROINTESTINAL INFECTION.  HE HAS HAD FEW VISITOR AND FEW OPPORTUNITIES TO LEAVE HIS ROOM.  HIS AMBULATION IS ALSO STILL LIMITED.  NURSING MEASURES TO REDUCE SENSORY DEPRIVATION INCLUDE: (SELECT ALL THAT APPLY)
    1.  ARRANGING FOR HIM TO HAVE A ROOMMATE
    2.  TURNING OFF THE LIGHTS AND CLOSING THE ROOM DRAPES
    3.  ARRANGING FOR PEACEFULNESS AND FREQUENT REST PERIODS
    4.  HELPING HIM TO A CHAIR OR BRINGING A FLOWER INTO THE ROOM
    5.  SITTING DOWN, SPEAKING, TOUCHING, AND LISTENING TO HIS FEELINGS AND PERCEPTIONS
    4.  HELPING HIM TO A CHAIR OR BRINGING A FLOWER INTO THE ROOM5.  SITTING DOWN, SPEAKING, TOUCHING, AND LISTENING TO HIS FEELINGS AND PERCEPTIONS
  32. THE HOME CARE NURSE IS INSTRUCTION A NURSING ASSISTANT ABOUT INTERVENTIONS TO FACILITATE LOCATION OF ITEMS FOR PATIENTS WITH VISION IMPAIRMENT.  WHICH STRATEGY IS NOT EFFECTIVE IN ENHANCING A PATIENT'S IMPAIRED VISION?
    1.  USE OF FLUORESCENT LIGHTING
    2.  USE OF WARM INCANDESCENT LIGHTING
    3.  USE OF COLORS WITH SHARP CONTRAST AND INTENSITY
    4.  USE OF YELLOW OR AMBER LENSES TO DECREASE GLARE
    1.  USE OF FLUORESCENT LIGHTING
  33. A 72 YEAR OLD PATIENT WITH BILATERAL HEARING LOSS WEARS A HEARING AID IN HER LEFT EAR.  WHICH OF THE FOLLOWING APPROACHES BEST FACILITATE COMMUNICATION WITH HER?
    1.  SPEAK DIRECTLY INTO THE PATIENT'S LEFT EAR
    2.  APPROACH THE PATIENT FROM BEHIND AND SPEAK FREQUENTLY
    3.  FACE THE PATIENT WHEN SPEAKING; SPEAK SLOWER AND IN A NORMAL VOLUME
    4.  FACE THE PATIENT WHEN SPEAKING; USE A LOUDER THAN NORMAL TONE OF VOICE
    3.  FACE THE PATIENT WHEN SPEAKING; SPEAK SLOWER AND IN A NORMAL VOLUME
  34. THE NURSE IS CARING FOR AN OLDER PATIENT WITH GLAUCOMA.  WHEN DEVELOPING A DISCHARGE PLAN, WHICH OF THE PRIORITY INTERVENTIONS ENABLES THE PATIENT TO FUNCTION SAFELY WITH EXISTING DEFICITS AND CONTINUE A NORMAL LIFESTYLE?
    1.  ENCOURAGE THE PATIENT'S FAMILY TO VISIT HIM OR HER ONCE A MONTH
    2.  SUGGEST TO THE PATIENT THAT HE OR SHE CONSIDER MOVING TO A LONG TERM CARE FACILITY
    3.  SAY NOTHING BECAUSE IT IS MOST APPROPRIATE THAT THE PATIENT IDENTIFY PERSONAL INTERVENTIONS TO COMPENSATE FOR A SENSORY ALTERATION
    4.  WORK CLOSELY WITH THE PATIENT TO IDENTIFY WAYS TO MODIFY HIS OR HER HOME ENVIRONMENT AND REFER TO APPROPRIATE COMMUNITY BASED RESOURCES
    4.  WORK CLOSELY WITH THE PATIENT TO IDENTIFY WAYS TO MODIFY HIS OR HER HOME ENVIRONMENT AND REFER TO APPROPRIATE COMMUNITY BASED RESOURCES
  35. A 74 YEAR OLD PATIENT WHO HAS RETURNED TO THE NURSING HOME FOLLOWING SURGICAL REMOVAL OF BILATERAL CATARACTS REPORTS FEELING A LITTLE UNCERTAIN ABOUT WALKING BY HERSELF.  WHICH OF THE FOLLOWING APPROACHES DO YOU USE TO ASSIST HER WITH AMBULATION?
    1.  WALK ONE HALF STEP BEHIND AND SLIGHTLY TO HER SIDE
    2.  HAVE HER GRASP YOUR ARM JUST ABOVE THE ELBOW AND WALK AT A COMFORTABLE PACE, WARNING HER WHEN YOU APPROACH OBSTACLES
    3.  ALLOW HER TO STAND ALONE IN UNFAMILIAR AREAS TO ENCOURAGE CONFIDENCE BUILDING
    4.  IF SHE REQUIRES ASSISTANCE, PLACE YOUR HAND AROUND HER WAIST
    2.  HAVE HER GRASP YOUR ARM JUST ABOVE THE ELBOW AND WALK AT A COMFORTABLE PACE, WARNING HER WHEN YOU APPROACH OBSTACLES
  36. BECAUSE HEARING IMPAIRMENT IS ONE OF THE MOST COMMON DISABILITIES AMONG CHILDREN, A HEALTH PROMOTION INTERVENTION IS TO TEACH PARENTS AND CHILDREN TO
    1.  AVOID ACTIVITIES IN WHICH THERE MAY BE CROWDS
    2.  DELAY CHILDHOOD IMMUNIZATIONS UNTIL HEARING CAN BE VERIFIED
    3.  PROPHETICALLY ADMINISTER ANTIBIOTICS TO REDUCE THE INCIDENCE OF INFECTIONS
    4.  TAKE PRECAUTIONS WHEN INVOLVED IN ACTIVITIES ASSOCIATED WITH HIGH INTENSITY NOISES
    4.  TAKE PRECAUTIONS WHEN INVOLVED IN ACTIVITIES ASSOCIATED WITH HIGH INTENSITY NOISES
  37. THE NURSE IS CONDUCTING DISCHARGE TEACHING FOR A PATIENT WITH DIMINISHED TACTILE SENSATION.  WHICH OF THE FOLLOWING STATEMENTS BY THE PATIENT WOULD INDICATE THAT ADDITIONAL TEACHING IS NEEDED?
    1.  I AM AT RISK FOR INJURY FROM TEMPERATURE EXTREMES
    2.  I MAY BE ABLE TO DRESS MORE EASILY WITH ZIPPERS OR PULLOVER SWEATERS
    3.  A HOME CARE REFERRAL MAY HELP ME ACHIEVE A MAXIMUM DEGREE OF INDEPENDENCE
    4.  I HAVE RIGHT SIDED PARTIAL PARALYSIS AND REDUCED SENSATION SO I SHOULD DRESS THE LEFT SIDE OF MY BODY FIRST
    4.  I HAVE RIGHT SIDED PARTIAL PARALYSIS AND REDUCED SENSATION SO I SHOULD DRESS THE LEFT SIDE OF MY BODY FIRST
  38. THE NURSE COMPLETES AN ASSESSMENT OF A 67 YEAR OLD FEMALE PATIENT WHO COMES TO THE CLINIC FOR THE FIRST TIME.  DURING THE EXAMINATION THE PATIENT'S TEMPERATURE IS 99.6 DEGREES F (37.6 DEGREES C), HEART RATE 80 BEATS/MIN, RESPIRATORY RATE 18 BREATHS/MIN, AND BLOOD PRESSURE 142/84 MM HG.  SHE IS NOT ATTENTIVE AS THE NURSE ASKS QUESTIONS.  AT ONE POINT, SHE SHOUTS ANSWERS TO QUESTIONS ABOUT HER DIET.  HOWEVER, AS THE NURSE SPEAKS, THE PATIENT CONSISTENTLY SMILES AND NODS IN AGREEMENT.  THE NURSE'S ASSESSMENT INDICATES:
    1.  A VISUAL DEFICIT
    2.  PATIENT IS NORMAL
    3. A HEARING DEFICIT
    4.  SENSORY OVERLOAD
    3. A HEARING DEFICIT
  39. WHEN COMMUNICATING WITH A PATIENT WHO HAS EXPRESSIVE APHASIA, THE HIGHEST PRIORITY FOR THE NURSE IS 
    1.  TO ASK OPEN ENDED QUESTIONS
    2.  TO UNDERSTAND THAT THE PATIENT WILL BE UNCOOPERATIVE
    3.  TO COACH THE PATIENT TO RESPOND
    4.  TO OFFER PICTURES OR A COMMUNICATION BOARD SO THE PATIENT CAN POINT
    4.  TO OFFER PICTURES OR A COMMUNICATION BOARD SO THE PATIENT CAN POINT
  40. A PATIENT WITH A HISTORY OF A HEARING DEFICIT COMES TO THE MEDICAL CLINIC FOR A ROUTINE CHECKUP.  HIS WIFE DIED 2 YEARS AGO, AND HE ADMITS TO FEELING LONELY MUCH OF THE TIME.  INTERVENTIONS THE NURSE USES TO REDUCE LONELINESS INCLUDE:  (SELECT ALL THAT APPLIES)
    1.  REASSURING THE PATIENT THAT LONELINESS IS A NORMAL PART OF AGING
    2.  PROVIDING INFORMATION ABOUT LOCAL SOCIAL GROUPS IN THE PATIENT'S NEIGHBORHOOD
    3.  MAINTAINING DISTANCE WHILE TALKING TO AVOID OVERSTIMULATING THE PATIENT
    4.  RECOMMENDING THAT THE PATIENT CONSIDER MAKING LIVING ARRANGEMENTS THAT WILL PUT HIM CLOSER TO FAMILY OR FRIENDS
    2.  PROVIDING INFORMATION ABOUT LOCAL SOCIAL GROUPS IN THE PATIENT'S NEIGHBORHOOD

    4.  RECOMMENDING THAT THE PATIENT CONSIDER MAKING LIVING ARRANGEMENTS THAT WILL PUT HIM CLOSER TO FAMILY OR FRIENDS
  41. A NURSE IS PERFORMING AN ASSESSMENT ON A PATIENT ADMITTED TO THE EMERGENCY DEPARTMENT WITH EYE TRAUMA.  THE NURSE'S PRIORITY INTERVENTIONS INCLUDE WHICH OF THE FOLLOWING?  (SELECT ALL THAT APPLY)
    1.  CONDUCTING A HOME SAFETY ASSESSMENT AND IDENTIFYING HAZARDS IN THE PATIENT'S LIVING ENVIRONMENT
    2.  REINFORCING EYE SAFETY AT WORK AND IN ACTIVITIES THAT PLACE THE PATIENT AT RISK FOR EYE INJURY
    3.  PLACING NECESSARY OBJECTS SUCH AS THE CALL LIGHT AND WATER IN FRONT OF THE PATIENT TO PREVENT FALLS DUE TO REACHING
    4.  ORIENTATING THE PATIENT TO THE ENVIRONMENT TO REDUCE ANXIETY AND PREVENT FURTHER INJURY TO THE EYE.
    3.  PLACING NECESSARY OBJECTS SUCH AS THE CALL LIGHT AND WATER IN FRONT OF THE PATIENT TO PREVENT FALLS DUE TO REACHING4.  ORIENTATING THE PATIENT TO THE ENVIRONMENT TO REDUCE ANXIETY AND PREVENT FURTHER INJURY TO THE EYE.
  42. WHICH PATIENT IS MOST LIKELY TO EXPERIENCE SENSORY DEPRIVATION?
    1.  A 79 YEAR OLD VISUALLY IMPAIRED RESIDENT OF A NURSING HOME WHO ENJOYS TAKING PART IN DIFFERENT HOBBIES AND ACTIVITIES
    2.  A 14 YEAR OLD GIRL ISOLATED IN THE HOSPITAL BECAUSE OF SEVERE IMMUNE SYSTEM SUPPRESSION
    3.  A HEARING IMPAIRED 66 YEAR OLD WOMAN WHO LIVES IN AN ASSISTED LIVING FACILITY
    4.  A 9 YEAR OLD BOY WHO IS DEAF AND USES SIGN LANGUAGE TO COMMUNICATE WITH HIS FRIENDS, FAMILY, AND TEACHERS
    2.  A 14 YEAR OLD GIRL ISOLATED IN THE HOSPITAL BECAUSE OF SEVERE IMMUNE SYSTEM SUPPRESSION
  43. THE MEDICAL RECORD OF AN OLDER ADULT REVEALS A STROKE AFFECTING THE RIGHT HEMISPHERE OF THE BRAIN.  WHICH OF THESE ASSESSMENT FINDINGS SHOULD THE NURSE EXPECT TO FIND?  (SELECT ALL THAT APPLY)
    1.  VISUAL SPATIAL ALTERATIONS SUCH AS LOSS OF HALF OF A VISUAL FIELD
    2.  LOSS OF SENSATION AND MOTOR FUNCTION ON THE RIGHT SIDE OF THE BODY
    3.  INATTENTION AND NEGLECT, ESPECIALLY TO THE LEFT SIDE
    4.  CLOUDY OR OPAQUE AREAS IN PART OF THE LENS OR THE ENTIRE LENS
    3.  INATTENTION AND NEGLECT, ESPECIALLY TO THE LEFT SIDE
  44. A NURSE IS PERFORMING A HOME CARE ASSESSMENT ON A PATIENT WITH A HEARING IMPAIRMENT.  THE PATIENT REPORTS, "I THINK MY HEARING AID IS BROKEN, I CAN'T HEAR ANYTHING"  WHIC OF THE FOLLOWING TEACHING STATEGIES SHOULD NOT BE IMPLEMENTED?
    1.  DEMONSTRATING HEARING AID BATTERY REPLACEMENT
    2.  REVIEWING METHOD TO CHECK VOLUME ON HEARING AID
    3.  DISCUSSING MEASURES FOR CLEANING BATTERY
    4.  TURNING DIAL TO MINIMUM SETTING AND , IN A LOUDER THAN NORMAL VOICE, ASKING THE PATIENT "IS THIS VOICE CLEAR"
    4.  TURNING DIAL TO MINIMUM SETTING AND , IN A LOUDER THAN NORMAL VOICE, ASKING THE PATIENT "IS THIS VOICE CLEAR"
  45. WHEN ASSESSING A 45 YEAR OLD PATIENT'S SENSORY STATUS, WHICH OF THE FOLLOWING ASSESSMENT FINDINGS DOES THE NURSE CONSIDER A NORMAL PART OF AGING?
    1.  PRESBYOPIA AND THE NEED FOR GLASSES FOR READING
    2.  REDUCED SENSITIVITY TO ODORS
    3.  IMPAIRED BALANCE AND COORDINATION
    4.  REDUCED TASTE DISCRIMINATION
    1.  PRESBYOPIA AND THE NEED FOR GLASSES FOR READING

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