A patient asks for a copy of her medical record. The best response by the nurse is to:

Indicate that she has the right to read her record

Elevate the head of the bed to sleep

Documented medication given by another nursing student

Witness the client's signature on the consent form

Notify the surgeon, Cover the area with sterile, saline-soaked towels and immediately

Early walking is the best way to prevent postoperative complications

Which assessment finding will best indicate that the patient is ready to learn?

Expresses the motivation to walk with an assistive device

Witness the permit after consent is obtained by the surgeon

Maintain consistency in the same bedtime ritual

The nurse would utilize the Snellen chart for assessment of which patient?

A pt who frequently reports the wrong time from the clock across the room

A nurse is developing a plan of care for an older adult. Which information will the nurse consider?

Needs to be individualized to the patient’s unique needs

Please read this handout and tell me what it means

What do you do just before going to bed?

Which assessment question should nurse ask to best understand how visual alterations affect the pt's self-care ability?

Are you able to prepare a meal or write a check?

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult?

All older adults, whether healthy or frail, need to express sexual feelings

Check his preoperative assessment for previous delirium or dementia

A nurse is caring for a postoperative patient. Which sign will alert the nurse to a potential wound dehiscence?

Report by patient that something has given way

Which intervention is appropriate to include on a care plan for improving sleep in the older adult?

Decrease fluids 2 to 4 hours before sleep

The patient's name, age, and admitting diagnosis, Allergies to food and medication

Provide only the information that the patient needs to go home

You are expected to perform at the level of a professional nurse

Administering adequate analgesics to promote relief or control of pain

Just before lunch, when the patient is most awake and alert, When the patient's pain medications are working

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A&D Care 1 Exam 3

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Questions 44

Answers

1
Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?
Social isolation
Impaired physical mobility
Risk for falls
Self-care deficit
2
A patient asks for a copy of her medical record. The best response by the nurse is to:
State that only her family may read the record
Tell her that she is not allowed to read her record
Explain that only health care workers have access to her record
Indicate that she has the right to read her record
3
15
Family member
Nurse
Nurse manager
Surgeon
4
13
Instruct the patient to sleep in a supine position
Elevate the head of the bed to sleep
Have patient limit fluid intake 2 hours before bedtime
Encourage patient to take an over-the-counter sleep aid
5
20
Stood with his back against the wall while documenting on the computers
Included the date and time of all entries in the chart
Signed all documentation electronically
Documented medication given by another nursing student
6
2
Notify the healthcare provider that the client is ready for the procedure
Document that the client has given consent for the needle aspiration
Verify the client's consent with the healthcare provider
Witness the client's signature on the consent form
7
19
1
4
3
2
8
24
Obtain pictures of food
Establish a rapport
Refer to a dietitian
Get an interpreter
9
11
Place several cold packs over the area, protecting skin around the wound
Notify the surgeon
Cover the area with sterile, saline-soaked towels and immediately
Cover the area with sterile gauze and apply an abdominal binder
10
The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?
Peripheral neuropathy
Cataracts
Xerostomia
Disequilibrium
11
5
Early walking is the best way to prevent postoperative complications
Early ambulation will help you be ready to go home
Early ambulation will help you get rid of your syncope and pain
Early walking keeps your legs limber and strong
12
Which assessment finding will best indicate that the patient is ready to learn?
The ability to grasp and apply the elastic bandage
Demonstrates sufficient coordination to handle a syringe safely
Has sufficient upper body strength to move from a bed to a wheelchair
Expresses the motivation to walk with an assistive device
13
33
C
A
B
D
14
3
Call a parent or legal guardian to sign the permit
Witness the permit after consent is obtained by the surgeon
Investigate your state's nurse practice act related to emancipated minors
Obtain verbal consent, since written consent is not necessary
15
28
Maintain consistency in the same bedtime ritual
Eliminate one of the naps during the day
Allow the child to sleep longer in the mornings
Offer the child a bedtime snack
16
22
Discovery
An analogy
A demonstration
Role play
17
The nurse would utilize the Snellen chart for assessment of which patient?
A patient who holds his newspaper 2 inches from his face
A patient who turns the television up as loud as possible
A pt who frequently reports the wrong time from the clock across the room
A pt who is having difficulty remembering how to perform familiar tasks
18
12
Hypothyroidism
Hypertension
Depression
Mild fatigue
19
A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
Focuses on the disabilities that all aging persons face
Should be standardized because most geriatric patients have the same needs
Needs to be individualized to the patient’s unique needs
Must be based on chronological age alone
20
41
The pediatric unit
Therapy dogs
Children
Anxiety
21
9
Slough
Eschar
Purulent drainage
Granulation
22
Which of the following sensory changes are normal with aging?
Impaired night vision
Difficulty hearing low pitch
Increase in taste discrimination
Heightened sense of smell
23
25
On a scale from 1 to 10, tell me where you rank your desire to learn
Do you feel strong enough to perform the tasks I will teach you?
What do you want to know about strokes?
Please read this handout and tell me what it means
24
18
What do you do just before going to bed?
Do you eat a small snack before going to bed?
Why don't you try napping more during the daytime?
Let's make sure that your bedroom is completely darkened at night
25
14
Oxygen humidification
Frequent change of position
Antibiotics
Chest physiotherapy
26
Which assessment question should nurse ask to best understand how visual alterations affect the pt's self-care ability?
Are you able to prepare a meal or write a check?
How do you protect yourself from injury at work?
How does your vision impairment make you feel?
Have you stopped reading books or switched to books on audiotape?
27
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Wound drainage
Cleansed wound
Necrotic tissue
Wound circumference
28
42
Peaceful music
The nursery
Infants
Breastfeeding moms
29
Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult?
A decrease in an older adult's libido occurs
All older adults, whether healthy or frail, need to express sexual feelings
Outward expression of sexuality means the OA is having a developmental prob
When the sexual partner passes away, the survivor no longer feels sexual
30
Teaching for a client who is currently taking a diuretic should include information that he or she may experience:
Nocturia
Increased daytime sleepiness
Reduced REM sleep
Nightmares
31
6
Check his preoperative assessment for previous delirium or dementia
Check which medications were used for anesthesia
Check the effectiveness of the analgesics he has received
Check his chart for intraoperative complications
32
A nurse is caring for a postoperative patient. Which sign will alert the nurse to a potential wound dehiscence?
Report by patient that something has given way
Protrusion of visceral organs through a wound opening
Chronic drainage of fluid through the incision site
Drainage that is odorous and purulent
33
38
The nurse's homeowner's insurance
The Good Samaritan laws
The nurse's automobile insurance
The Patient Care Partnership
34
Which intervention is appropriate to include on a care plan for improving sleep in the older adult?
Take a nap during the day to make up for lost sleep
Exercise in the evening to increase fatigue
Decrease fluids 2 to 4 hours before sleep
Allow the patient to sleep as late as possible
35
44
New-onset dementia
Depression
Delirium
Worsening dementia
36
30
The patient's name, age, and admitting diagnosis
Allergies to food and medication
How much the patient ate for breakfast
Your evaluation that the patient is "needy"
37
7
A
D
C
B
38
16
Convince the patient that learning about her health is necessary
Teach the patient's spouse
Provide only the information that the patient needs to go home
Focus on knowledge the patient will need in a few weeks
39
26
Cognitive
Kinesthetic
Psychomotor
Affective
40
39
You are practicing under the license of the nurse assigned to the patient
You are expected to perform at the level of a skilled nursing assistant
You are expected to perform at the level of a nursing student
You are expected to perform at the level of a professional nurse
41
40
Invasion of privacy
Battery
Assault
An unintentional tort
42
4
Asking the patient to demonstrate the postoperative exercises every 1 hour
Administering adequate analgesics to promote relief or control of pain
Give pt positive feedback when the activities are performed correctly
Warning pt about possible complications if the activities are not performed
43
27
When the patient is talking about current stressors in his or her life
Just before lunch, when the patient is most awake and alert
When there are visitors in the room
When the patient's pain medications are working
44
37
Expressive
Mixed
Global
Receptive

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