PROCTORED EXAM
Save Groups
Terms in this set (80)
A 73-year-old female client had a B. "Place a pillow between your knees while lying
hemiarthroplasty of the left hip in bed to prevent hip dislocation."
yesterday due to a fracture (The client's affected hip joint following a
resulting from a fall. In reviewing hemiarthroplasty (partial hip replacement) is at
hip precautions with the client, risk of dislocation for 6 months to a year
which instruction should the nurse following the procedure. Hip precautions to
include in this client's teaching prevent dislocation include placing a pillow
plan? between the knees to maintain abduction of the
A. "In 8 weeks you will be able to hips (B). Clients should be instructed to avoid
bend at the waist to reach items on bending at the waist (A), to seek assistance for
the floor." both standing and walking until they are stable
B. "Place a pillow between your on a walker or cane (C), and to take pain
knees while lying in bed to prevent medication 20 to 30 minutes prior to physical
hip dislocation." therapy sessions, rather than waiting until the pain
C. "It is safe to use a walker to get level is high after their therapy.)
out of bed, but you need assistance
when walking."
D. "Take pain medication 30 minutes
after your physical therapy
sessions."
,An adult male client with a history A. "It is important that you continue your
of hypertension tells the nurse that medication while learning to meditate."
he is tired of taking (The prolonged practice of meditation may lead
antihypertensive medications and is to reduced need for antihypertensive
going to try spiritual meditation medications. However, the medications must be
instead. What should be the nurse's continued (A) while the physiologic response to
first response? meditation is monitored. (B) is not as important as
A. It is important that you continue continuing the medication. The HCP should be
your medication while learning to informed, but permission is not required to
meditate. mediate (C). Although, it is true that the
B. Spiritual meditation requires a complimentary therapy might be effective (D), it
time commitment of 15 to 20 is essential that the client continue with
minutes daily. antihypertensive mediations until the effect of
C. Obtain your healthcare mediation can be measured.)
provider's permission before
starting meditation.
D. Complementary therapy and
western medicine can be effective
for you.
An African-American grandmother A. Inquire about the source and type of pain
tells the nurse that her 4-year-old (Different cultural groups often have their own
grandson is suffering with terms for health conditions. African-Americans
"miseries." Based on this statement, clients may refer to pain as "the miseries." Based
which focused assessment should on understanding this term, the nurse should
the nurse conduct? conduct a focused assessment on the source and
A. Inquire about the source and type of pain (A). (B, C, and D) are important, but
type of pain. do not focus on "miseries" (pain).)
B. Examine the nose for congestion
and discharge.
C. Take vital signs for temperature
elevation.
D. Explore the abdominal area for
distention.
,After completing an assessment A. Determine the etiology of the problem.
and determining that a client has a (Before planning care, the nurse should
problem, which action should the determine the etiology, or cause, of the problem
nurse perform next? (A), because this will help determine (B, C, and
A. Determine the etiology of the D). )
problem.
B. Prioritize nursing care
interventions.
C. Plan appropriate interventions.
D. Collaborate with the client to set
goals.
At the beginning of the shift, the D. Immediately after the assessments are
nurse assesses a client who is completed.
admitted from the post-anesthesia
care unit (PACU). When should the
nurse document the client's
findings?
A) At the beginning, middle, and
end of the shift.
B) After client priorities are
identified for the development of
the nursing care plan.
C) At the end of the shift so full
attention can be given to the
client's needs.
D) Immediately after the
assessments are completed
, At the time of the first dressing C. "It is OK if you don't want to talk about your
change, the client refuses to look at surgery. I will be available when you are ready."
her mastectomy incision. The nurse ( (C) displays sensitivity and understanding
tells the client that the incision is without judging the client. (A) is judgmental in
healing well, but the client refuses that it is telling the client how she feels and is also
to talk about it. What would be an insensitive. (B) would give the client a chance to
appropriate response to this client's talk, but is also demanding and demeaning. (D)
silence? displays a positive action, but, because the
A. "It is normal to feel angry and nurse's personal support if not offered, this
depressed, but the sooner you deal response could be interpreted as dismissing the
with this surgery, the better you will client and avoiding the problem.)
feel."
B. "Looking at your incision can be
frightening, but facing this fear is a
necessary part of your recovery."
C. "It is OK if you don't want to talk
about your surgery. I will be
available when you are ready."
D. "I will ask a woman who has had
a mastectomy to come by and
share her experiences with you."