NUR 107 Midterm Exam - Questions and Answers

NUR 107 Midterm Exam - Questions and Answers A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs? Attempt to calm the client and administer oxygen A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? Anticipatory guidance Which response to stressors results from the activation of the local adaptation syndrome (LAS)? A girl quickly withdraws her hand from a stream of hot tap water. A client who responds to bad news concerning laboratory results by crying uncontrollably is handling stress by using: coping mechanism Which client is handling stress by using the defense mechanism termed displacement? A mother who is angry at her husband shouts at the kids to "keep quiet." After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify? Rationalization An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? inspiration and expiration A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? prolonging expiration to reduce airway resistance While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? Submerge the end of the chest tube in a container of sterile water. A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? high fowlers Which nursing action will assist in pain management for a client in the postoperative phase? relaxation techniques A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? Instruct the client to exhale gently and completely before inhaling. A nurse asks a preoperative client which medications he is currently taking. Which statement describes an accurate guideline for client teaching regarding these medications? Many respiratory drugs may be taken the day of surgery per health care provider's order A nurse is assigned to be the circulating nurse during a surgical procedure. The nurse would be responsible for which activity? Anticipating the needs of other members of the surgical team Accommodation the process by which the eye's lens changes shape to focus near or far objects on the retina- Hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. Ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object (Figure C). Adrenocorticotropic hormone (ACTH) plays a large role in how your body responds to stress. ACTH is produced in the pituitary gland, its production stimulates the production and release of cortisol from the adrenal gland. ADH released from the posterior pituitary when stimulated by decreased blood volume and blood pressure, or by an increased osmolality of body fluids. It has a direct vasoconstricting effect on blood vessels, increasing peripheral resistance. hormone