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40 Cards in this Set
- Front
- Back
The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
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Activity intolerance related to pain
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The nurse selects a variety of teaching methods to use with clients. For a toddler, the nurse should use:
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Simple explanations and pictures
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The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is:
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Telling
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The nurse is demonstrating to the client how to put on anti-embolytic stockings. In the middle of the lesson, the client asks, “Why have my feet been swelling?†The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should adhere to?
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Timing
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The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
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Activity intolerance related to pain
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A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:
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Position the client upright
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The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. The nurse should:
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Assist the client to obtain the necessary information to make this decision
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A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, “I wonder why this happened to me?†According to Kübler-Ross, the nurse identifies that this stage is associated with:
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Denial
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Hospice nursing care has a different focus for client. The nurse is aware that client care provided through a hospice is:
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Designed to meet the client’s individual wishes, as much as possible
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The nurse is using Bowlby’s phases of mourning as a framework for assessing the client’s response to the traumatic loss of her leg. During the “yearning and searching†phase, the nurse anticipates that the client may respond by:
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Crying off and on
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The mother of a 2-year-old tells the nurse that the child has started crying and resisting going to sleep at the scheduled bedtime. The nurse should advise the parent to:
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Maintain consistency in the same bedtime ritual
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The nurse is completing an assessment on the client’s sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is:
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“Do you snore loudly or experience headaches?â€
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For a client who is currently taking a diuretic, the nurse should inform the client that he or she may experience:
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Nocturia
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Which of the following information provided by the client’s bed partner is most associated with sleep apnea?
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Excessive snoring
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The nurse is discussing sleep habits with the client in the sleep-assessment clinic. Of the following activities performed before sleeping, the nurse is alert to the one that may be interfering with the client’s sleep, which is:
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Finishing office work
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The nurse has completed the admission assessment for a client admitted to the hospital’s subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is:
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Injury, risk for
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With advancing age, which of the following normal physiological changes in sensory function occurs?
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Decreased sensitivity to pain
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The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:
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Use visual aids such as the hands and eyes when speaking
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The client has hyperesthesia apparently associated with a neurologic trauma. Which of the following is an appropriate nursing intervention in regard to the client’s sense of touch?
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Keeping the client loosely covered with sheets and blankets
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The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:
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Using a picture chart for the client’s responses
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The nurse completes a safety assessment during a home visit to an older adult client. Of the following observations made by the nurse, the one that is of greatest concern for this client who has evidence of sensory impairment is:
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The gray/black settings on the stove handles
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necessary loss
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have all your life, come with everyday life
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actual loss
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when you lose a person or object that can no longer be felt or known
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percieved loss
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anything defined by the cliebt
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maturational loss
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ex: child going to kindergarten or empty nest syndrome
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situational loss
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sudden or pnpredictable loss, tornado for example
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grief
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emotional response to loss
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mourning
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outward social expression of loss
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beraevement
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emotional response, inner feelings, and outward reaction of the survivor
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Kubler- Ross stages of dying
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denial
anger bargaining depression acceptance |
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Bowlby's theory of grief
phases of mourning |
numbing
yearning and searching disorganization and despair reorganization |
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Worden's theory of grief
4 tasks of mourning |
accept reality of loss
walk through pain of grief adjust to environment in which deceased is missing emotionally relocate deceased and move on with life |
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complicated grief
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chronic grief
delayed grief exaggerated grief masked grief |
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nursing process- planniong
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select commuinication strategies that assist client in accepting the loss
select intervention design to maintain dignity and self esteem provide skills and knowledge for family to manage and care for the dying |
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documenting pain
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location
intensity quality duration variations, rythyms causes relief measures effects of pain manner of expressing pain |
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assessing pain
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WILD SCARF
when does it occur intensity location duration does it affect quality of sleep affect ability to concentrate affect appetite or activity level? affect relationships? in fluence fatigue or functioning? |
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3 step analgesic ladder
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0-3 mild pain
4-6 mild to moderate pain 7-10 moderate to severe pain |
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mild pain
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non opioid or adjuvant
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mild to moderate pain
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opioid
non opioid adjuvant |
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moderate to severe pain
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opioid
non opioid adjuvant |