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111 Units 5&6 (2) Flashcards | StudBud
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111 Units 5&6 (2)
111 Units 5&6 (2)
75 terms
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Sleep, comfort, documentation
Flashcards
75 cards
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Practice quiz
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Questions
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Answers
1
When should the nurse assess pain?
Only when the patient complains of pain
Every 4 hours for the first 2 days after surgery
During the admission interview
Whenever a full set of vital signs is taken
2
What is the purpose of using a sleep diary?
Identify sleep–rest patterns over a 1-year period.
Ask about patterns of sleep during night and naps during day
Note trend in sleep–wakefulness patterns over 2 weeks.
Note typical sleep habits and most common daily routines.
3
An older pt is talking with a nurse about sleep problems. What should the nurse teach this pt?
The need for sleep decreases with age.
Elderly do not experience as much deep sleep as young people
A person should not awaken more than once during the night.
All elderly persons experience disrupted sleep & depression.
4
The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will:
Verbalize that she is sleeping better and less fatigued.
Consume only one caffeinated beverage per day.
Limit exercise to 1 hour per day early in the day.
Demonstrate effective guided imagery to aid relaxation.
5
During education of new parents about newborn sleep patterns, a nurse states that newborns:
Will nap two times per day
Are inactive when awake
Sleep 16 to 17 hours per day
Have shorter periods of REM sleep
6
Which of the following is a disadvantage of paper health records?
Are sometimes illegible
Assist collaboration
Provide cautionary reminders
Serve as a resource
7
Which misconception is common in clients in pain?
“I need to ask for pain medications.”
“I do not have to fight the pain without help.”
“The nurses are here to help relieve the pain.”
“I will get addicted to pain medications.”
8
Which of the following is the most common major challenge for older adults?
Chronic health problems leading to the loss of independence
Dealing with the needs of their children
The decline of intellectual abilities
Loss of the ability to reminisce about the past
9
What should be included in teaching parents of infants & toddlers about pain?
Toddlers often try to be brave and not cry
Toddlers are often reluctant to express pain
Infants cannot express pain until 8 months of age
Pain can be a source of fear/threat to a toddler’s security
10
In general, what is the focus of care for nurses who work with older adults?
Establishing goals and expected outcomes for the client
Referring clients for needed emotional support
Assisting clients to function as independently as possible
Providing all necessary physical care
11
Which patient teaching would be most therapeutic for someone with sleep disturbance?
Give yourself at least 60 minutes to fall asleep.
Avoid eating carbohydrates before going to sleep.
Do not go to bed feeling upset about a conflict.
Catch up on sleep by napping or sleeping in when possible.
12
Besides controlling pain of the post-surgery pt with narcotics, the nurse suggests that he …
think about the next dose
focus on pain relief
use distraction
describe the pain
13
Of the following individuals, who can best determine the experience of pain?
The physician diagnosing the cause
The person’s immediate family
The nurse caring for the client
The person who has the pain
14
From what stage of sleep are people typically most difficult to arouse?
REM
NREM, alpha waves
NREM, delta waves
NREM, sleep spindles
15
The nurse is assessing a pt. Which finding might indicate that this pt is experiencing pain?
Temperature 100.6°F
Oxygen saturation 95%
Blood pressure 160/82 mm Hg
Heart rate 80 beats/min
16
A pt is asked to rate his pain on a scale of 0-10. What characteristic is the nurse assessing?
chronology
duration
intensity
location
17
Which of the following factors has the greatest positive effect on sleep quality?
Sleeping hours in synchrony with the pt’s circadian rhythm
Napping frequently during the day hours
Sleeping in a quiet environment
Spending additional time in stage IV of the sleep cycle
18
A pt has pain in the left arm secondary to coronary insufficiency. This is what type of pain?
Referred pain
Subacute pain
Chronic pain
Acute pain
19
The nurse recommends that normal sleep patterns can be acquired by suggesting to the pt. to:
smoke cigarettes.
take a nap during the day.
exercise in the mornings.
drink wine.
20
How may a nurse demonstrate cultural competence when responding to clients in pain?
Treat every client exactly the same, regardless of culture.
Avoid stereotyping responses to pain by clients.
Be knowledgeable and skilled in medication administration.
Know the action and side effects of all pain medications.
21
What is the purpose of completing an occurrence report?
Track problems and identify areas for quality improvement
Legal defense if a pt seeks legal action after an occurrence
Report errors to the Food and Drug Administration
Report medical errors to the Joint Commission
22
A mother of a baby wants to learn to do CPR. What teaching strategy would be most effective?
lecture
demonstration
discovery
discussion
23
During stage 3 sleep, the patient may experience
Enuresis
Shortness of breath
Diaphoresis
Anxiety
24
The nurse identifies pain described by a pt whose back discomfort has persisted for 8 months as
Recurrent
Chronic
Malignant
Acute
25
A pt experiencing pain because of severe arthritis would be described as having _______ pain.
episodic
acute
chronic
phantom
26
A nurse is caring for a pt from Taiwan who requests pain meds. What should the nurse consider?
Pain in adults in less intense than pain in children.
The client has a low pain tolerance.
Most people react to pain in the same way.
Pain is what the client says it is.
27
Which would be appropriate for a pt. who says that he has trouble falling asleep every night?
Drink a glass of milk with a turkey sandwich
Exercise vigorously for 30 minutes before sleep
Take a warm shower before bedtime
Clean the bedroom prior to falling asleep
28
What is typically the most reliable indicator of pain?
Behavioral cues
Past medical history
Patient’s self-report
Description by caregiver(s)
29
A pt having asks what the complications of sleep deprivation are. What should the nurse answer?
Development of Alzheimer’s disease
Fatigue occurring at night
Improved wound healing
Auditory hallucinations
30
A male nurse is to assess vitals of a female pt. Which ethnic group would find this improper?
Arab Muslim
White
African American
Native American
31
Which of the following is a nonverbal behavior that enhances communication?
Asking mostly open-ended questions
Keeping a neutral expression on the face
Maintaining a distance of 6 to 12 inches
Sitting down to speak with the patient
32
A pt. has had knee pain for 3 years with diminished mobility. The best nursing diagnosis is:
Chronic pain r/t knee disability as defined by guarded gait
Inability to perform ADLs related to chronic pain
Acute pain related to djd as evidenced by static gait
Altered mobility related to pain as defined by guarded gait
33
Because a person may learn best in a particular manner, to improve pt teaching, a nurse should:
use a combination of the 3 modes to enhance learning.
use a hands-on approach; it works best for most people.
test the pt’s reading ability before using visual handouts.
ask if pt learns best visually, aurally, or kinesthetically.
34
A pt suddenly develops RLQ pain & rebound tenderness. How should a nurse classify the pain?
neuropathic
acute
intractable
chronic
35
Which of the following reflects an understanding of the characteristics of older adults?
Average life expectancy has declined over the past 10 years.
Black men have the lowest life expectancy.
In general, males tend to live longer than do females.
Fewer than 5% of all older adults live in nursing homes.
36
The nurse appropriately begins discharge planning when:
the physician writes orders to discharge the patient.
the patient is admitted to the health care facility.
the patient feels ready to be discharged home.
it is anticipated the patient will be discharged in 8 hours.
37
What is a nurse required to do to adhere to the concept of confidentiality of a medical record?
Share information only with the family
Provide information only to an attorney
Provide information only to another nurse
Have a clinical reason for reading the record
38
A patient refuses a dose of medication. How should the nurse document the event?
Patient refuses the 0900 dose of digoxin.
Patient is belligerent and refuses the 0900 dose of digoxin.
0900 dose of digoxin not given.
Patient is uncooperative & refuses the dose of digoxin.
39
During the first cycle of sleep, the patient will be in REM sleep for
6 minutes
15 minutes
3 minutes
1 hour
40
Charting in which the nurse writes a progress note that relates to one health problem is a:
SOAP note
Flow sheet
Narrative note
PIE note
41
The nurse should include which of the following interventions to improve a preschooler's sleep?
The child should drink milk at bedtime
The child should sleep with the parents
The parents should keep the child up until 10 PM
Have the child limit fluids after supper
42
Which of the following strategies might a nurse use to increase compliance with education?
Maintain clear role as the authority.
Include the client and family as partners.
Use short, simple sentences for all ages.
Provide verbal instruction at all times.
43
A person who is deprived of REM sleep for several nights in succession will usually experience:
Extended NREM sleep.
REM rebound.
Insomnia.
Paradoxical sleep.
44
Once a teaching plan is formulated and placed in the nursing care plan for a hospitalized pt:
One nurse will be designated to teach the plan
behavioral objectives identify expected outcomes.
it is printed and given to the pt as a guide for learning.
it outlines what will be taught before the pt is discharged.
45
The primary focus of your interventions for a 6-year-old child who sleepwalks would be to:
Encourage the pt. to verbalize feelings regarding sleep.
Provide a quiet environment for nighttime sleep
Administer and teach about meds to suppress stage IV sleep.
Maintain patient safety during episodes of somnambulation.
46
The best intervention by a nurse for a child who is having difficulty falling asleep would be:
turning off all of the lights in the room.
having the parents bring a favorite blanket from home.
giving of juice and cookies before being put to bed.
keeping a night light on in the room.
47
Which statement indicates understanding of the appropriate way to document a charting error?
“I can draw a red circle around it.”
“I have to rewrite the entire entry.”
“I can use white-out on it.”
“I draw a single line through it and put my initials by it.”
48
What is the most critical element of documentation of education?
Evidence that learning has occurred
The implementation of the education plan
A summary of the education plan
the client’s need for learning
49
The (QSEN) project has identified the most important pre-licensing skills for nurses as:
informatics.
familiarity with medical terms.
writing nursing care plans.
effective communication.
50
A nurse evaluates the effectiveness of teaching how to use an eye shield after eye surgery by:
have the patient tell the nurse what he is going to do.
have the pt demonstrate that he can secure the eye shield.
call the pt and ask if he has been wearing the shield.
ask the pt if he has questions related to using the shield.
51
2 hours after receiving pain meds, a pt. says he still has pain. The nurse should first ask:
“Do you need your pain medication now?”
“Please describe your pain on a scale of 0 to 10.”
“Tell me more about your pain.”
“Tell me where your pain is located.”
52
Most acute pain is intense and of short duration. How long does acute pain usually last?
Less than 6 months
At least 9 months
1 week
More than 1 year
53
A nurse is caring for a pt with acute back pain. When should the nurse assess the pt’s pain?
Once per day when the pain is a potential problem
After the client is discharged from the health care facility
Six hours after administering a prescribed analgesic
Whenever the vital signs are measured and documented
54
A nurse recognizes the American Indian’s need for a shaman because a shaman helps the pt. seek:
support from deceased ancestors.
healing through the domination over evil.
a spiritual route to healing.
a sense of peace and harmony with nature.
55
The nurse clarifies that the first stage of wound healing is:
maturation.
reconstruction.
inflammation.
proliferation.
56
When using the SBAR model to communicate with a physician, what info does a nurse offer first?
A solution or what is needed from the physician
Statement of the problem and its probable cause
History of infor related to and leading up to the situation
Nurse’s name, pt’s name, and reason for the communication
57
A child describes intense pain in the chest & head while eating a popsicle. The pain is termed:
Hyperalgesia
Fear
Allodynia
Thermal stimulation
58
The nurse assesses a child for pain. If pain level is not addressed, what problem could occur?
Respiratory compromise
Urinary retention
Bradycardia
Bowel obstruction
59
While instructing young adults about sleep, the nurse states that to improve sleep quality:
Catch up on sleep on days off from work
Have a consistent time for arising
Stay awake until midnight consistently
Take an afternoon nap whenever possible
60
When assessing a pt’s pain, a nurse should ask about location, intensity, quality of pain, and:
Objective signs
Temporal pattern
Pain tolerance
Level of consciousness
61
When teaching an elderly pt about changing his dressing, the nurse would most appropriately:
point out each mistake during the return demonstration.
talk rapidly to keep the patient from becoming tired.
be certain the pt is wearing his glasses and/or hearing aid.
wait for the pt to ask any questions about the procedure.
62
Besides controlling pain of the post-surgery patient with narcotics, the nurse suggests to:
Focus on pain relief
Think about the next dose
Describe the pain
Use distraction
63
The nurse assesses a pt’s sleep for NREM sleep because this sleep has the characteristics of:
daytime activity.
offering the most rest.
irregular respirations.
increased heart rate.
64
Which intervention by the nurse first helps to establish a trusting nurse-patient relationship?
Performing care interventions quietly and respectfully
Greeting the pt by name whenever entering the patient’s room
Avoid topics that may provoke emotional responses from a pt.
Listening to the patient while performing care activities
65
Why is documentation especially significant in managed care?
Institutions are reimbursed for pt. care that is documented.
The hospital needs to show that employees care for patients.
Patients might bring lawsuits if care was not given.
Documents may become part of a lawsuit.
66
A nurse is showing a diabetic pt how to draw insulin out of a syringe. This mode of learning is
auditory
kinesthetic
oral
visual
67
The nurse uses the flow sheet in patient care documentation primarily:
for continuity of care & exchange of info among disciplines.
to eliminate written narratives and to save time.
to track assessments, treatments, & frequently given care.
in computer charting to create visual graphs showing change.
68
Patterns of waking behavior that appear during sleep are known as:
Insomnia.
Hypersomnia.
Parasomnias.
Dyssomnias.
69
Which principles should guide the nurse’s documentation in a patient's medical record?
Nurses may not document for another health professional.
Documentation does not include photographs.
Precise measurements are preferred over approximations.
Nurses should not refer to the names of physicians.
70
Which of the following problems is associated with obesity, heavy snoring, & shallow breathing?
Hypersomnia
Sleep apnea
Hyperpnea
Narcolepsy
71
A pt is sleeping, has irregular respirations, & is showing eye movement. The stage of sleep is:
Light sleep
Slow wave
Transitional
Rapid eye movement (REM)
72
Quoting statements made by a newly admitted patient when documenting will help in maintaining:
Objectivity
Organization
Reimbursement
Subjectivity
73
The nurse will plan to offer the teaching session in a quiet area in order to:
ensure that the patient can hear what the nurse says.
reduce distractions.
make the environment more like a classroom.
provide absolute privacy.
74
Which of the following is the main difference between sleep and rest?
In sleep, the body may respond to external stimuli.
Short periods of sleep does not restore a pt as much as rest
The metabolism slows less during sleep than during rest.
Sleep is characterized by an altered level of consciousness.
75
Which is a major factor regulating sleep?
Electrical impulses transmitted to the cerebellum
Amount of light received through the eyes
Amount of sleep a person has become accustomed to
Level of sympathetic nervous system stimulation
