Fundamentals Exam #2

Question 1

A nurse should perform what interventions to prevent joint contractures? Select all that apply:

Accepted Answer

Perform ROM exercises, Splinting, Use proper positioning in proper body alignment

Question 2

Body alignment is:

Accepted Answer

the relationship of 1 body part to another in dif. positions

Question 3

When is the best time to implement teaching:

Accepted Answer

When an activity directly related to teaching is performed

Question 4

Somatic pain:

Accepted Answer

In bones, joints, muscles, skin, or connective tissue

Question 5

Affective learning is:

Accepted Answer

Expression of feelings and development of values, attitudes

Question 6

Pain is a protective mechanism warning of tissue injury and is largely a:

Accepted Answer

Subjective experience

Question 7

Flexor muscles for joints are stronger than extensor muscles and can contribute to contractures

Accepted Answer

True

Question 8

Evisceration is:

Accepted Answer

Protrusion of organs through a wound opening

Question 9

Primary intention in wound healing:

Accepted Answer

edges are approximated

Question 10

Demonstration of proper body mechanics would be classified under which domain of learning?

Accepted Answer

Psychomotor

Question 11

An unstageable pressure ulcer is:

Accepted Answer

Depth of ulcer unknown due to eschar in wound bed

Question 12

The inability to name common objects or express simple ideas in words or writing is:

Accepted Answer

Expressive aphasia

Question 13

Global aphasia is:

Accepted Answer

Inability to understand language or communication orally

Question 14

The patient states that they best learn by a hands-on approach. This type of learning is:

Accepted Answer

Kinesthetic

Question 15

Which of the following are primary risk factors for pressure ulcers? Select all that apply:

Accepted Answer

low-protein diet, lengthy surgical procedure

Question 16

Which is an appropriate intervention to maintain respiratory system in an immobilized patient?

Accepted Answer

Encourage the pt. to deep breathe and cough every 1-2 hours

Question 17

Stage IV pressure ulcer is:

Accepted Answer

Full-thickness tissue loss with exposed bone, muscle, tendon

Question 18

Drug tolerance:

Accepted Answer

Patient requires higher doses to control pain

Question 19

Learning objectives are:

Accepted Answer

What the learner will be able to accomplish after teaching

Question 20

How should the nurse asses a patient's intensity of pain?

Accepted Answer

Offer the client a pain scale to measure his pain.

Question 21

Signs of a wound infection include (select all that apply):

Accepted Answer

Purulent drainage, increased redness, Edema, warmth

Question 22

The referent in the communication process is:

Accepted Answer

That which motivated the communication

Question 23

A client’s wound is draining thick yellow material. The nurse describes the drainage as:

Accepted Answer

Purulent

Question 24

Immobility disrupts normal metabolic functioning by all of the following except:

Accepted Answer

Increases metabolic rate

Question 25

All of the following are steps of the teaching process except:

Accepted Answer

Diagnosis

Question 26

A patient's organs are protruding through a wound. The nurse should: Select all that apply

Accepted Answer

Call for help, Cover with moist sterile gauze

Question 27

Secondary intention in wound healing:

Accepted Answer

the wound is left open until filled with scar tissue

Question 28

Passive ROM should be performed:

Accepted Answer

to the point of resistance

Question 29

An underweight pt. has a stage III pressure ulcer. The most important supplement to increase:

Accepted Answer

Protein

Question 30

Psychosocial changes that can occur an in immobile patient include all of the following except:

Accepted Answer

increased socialization

Question 31

When foot drop occurs, the foot is fixated in:

Accepted Answer

Plantar flexion

Question 32

After pain medication administration, the nurse should:

Accepted Answer

Reassess pain level within 1 hour of pain medication admin

Question 33

An equal partnership among members of a teaching team in the nurse patient relationship is:

Accepted Answer

Mutuality

Question 34

Stage III pressure ulcer is:

Accepted Answer

Full-thickness tissue loss with visible fat

Question 35

Stage II pressure ulcer is:

Accepted Answer

Partial-thickness skin loss w/ epidermis, or dermis, or both

Question 36

Before moving an immobile patient, the nurse needs to do what first?

Accepted Answer

Assess patient's weight and determine assistance needs

Question 37

What is the best way to promote sensory stimulation to a sensory deprived patient?

Accepted Answer

Direct physical contact

Question 38

A person's tolerance to sensory overload can vary according to all of the following except:

Accepted Answer

Quiet environment

Question 39

A patient has a PCA. Which of the following is true regarding a PCA.?

Accepted Answer

The patient is the only person who can push the button

Question 40

Stage one pressure ulcer:

Accepted Answer

Can be reversed, can leave open to air because intact skin

Question 41

A pt. is receiving opioid analgesia. What are some adverse effects? Select all that apply:

Accepted Answer

bradypnea, constipation, nausea & vomitting

Question 42

The standards of patient education include:

Accepted Answer

Standard for professional nursing practice, Necessary for patient-centered care & safety, Always documented in the chart, TJC sets standards for patient and family education

Question 43

Adjuvants are:

Accepted Answer

enhance analgesics

Question 44

The purposes of patient education include (select all that apply):

Accepted Answer

Restoration of health, promotion of health and illness prevention, Reduce health care cost by improving patient outcomes, coping with impaired functioning

Question 45

There is a respiratory change in your immobilized postop patient. This is consistent with:

Accepted Answer

Atelectasis

Question 46

Gate control theory distraction techniques include: Select all that apply

Accepted Answer

breathing techniques, meditation, relaxation

Question 47

Cardiovascular changes in an immobile patient include all except:

Accepted Answer

Decreased cardiac workload

Question 48

Which phase of the helping relationship involves determineing outcomes of the interaction?

Accepted Answer

Working

Question 49

In caring for an immobile patient, the nurse should assess the respiratory system how?

Accepted Answer

Auscultate to lung sounds in all lung fields

Question 50

A pt. is having difficulty understanding when to perform glucose testing. The nurse should:

Accepted Answer

consult & involve diabetic specialist/educator

Fundamentals Exam #2

Questions 50

Fundamentals Exam #2

Questions 50