The nurse is assessing a group of clients. Which clients
are at greater risk for hypothermia or frostbite? (select all
that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses
are at greater risk for hypothermia. Clients who smoke, consume
alcohol, or have impaired peripheral circulation have a higher
incidence of frostbite.
The nurse is caring for four clients. Which client
assessment is the most indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision
B
At times clients are unable to verbalize that they are in pain but
there are indicators that the client may have acute pain such as
increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the
other distractors could indicate clients who have the potential for
being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse
educator would explain that informal teaching is an
approach that
,a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which
represents the majority of patient education done by nurses that
occurs when an intervention is explained or a question is
answered. Group needs are often the focus of formal patient
education courses or classes. Informal teaching does not
necessarily follow a specific formalized plan. It may be planned
with specific content, but it is individualized responses to patient
needs. Formal teaching involves the use of a curriculum/course
plan with standardized content.
A patient expresses a strong interest in returning to their
work, family, and hobbies after having a stroke. Which
theory type would the nurse use to develop a plan of care
for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when
integrated, motivate someone to learn. Field theorists place
significance on how achievement, power, the need for affiliation,
and avoidance motives influence individual behavior. Sociologic
theories are not involved in motivation.
Which statement made by a nurse represents the need for
further education regarding pain management in older
adult clients?
a. older adults tend to report pain less often than younger
adults
,b. older clients usually have more experience with pain
than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do
not feel it as much
D
There is no evidence to support the idea that older adult clients
perceive pain any differently than younger clients. The other
statements are accurate regarding older clients and pain.
The nurse is working at a first aid booth for a spring
training game on a hot day. A spectator comes in,
reporting that he is not feeling well. Vital signs are temp
104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood
pressure 106/66 mm Hg. He trips over his feet as the
nurse leads him to a cot. What is the priory action of the
nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical
emergency. The spectator should be transported to the ED ASAP.
The nurs should take actions to lower his body temp in teh
meantime by removing his shirt and sponging his body with cool
water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The
client needs to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium
chloride ina 1000 mL solution of dextrose 5% in 0.45%
saline. The client states that the area around the IV site
burns. What intervention does the nurse perform first?
, a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion
D
Potassium is a severe tissue irritant. The safest action is to
discontinue the solution that contains the potassium and
discontinue the IV altogether, in which case the client would need
another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and
the rate could be slowed once it is determined that the needle is
in the vein.
A nurse is caring for an older adult client who lives alone.
Which economic situation presents the most serious
problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
D
Older adults on fixed incomes are unable to adjust their income to
meet rising costs associated with meeting basic needs
Controlling pain is important to promoting wellness.
Unrelieved pain has been associated with
a. prolonged stress response and a cascade of harmful
effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction
are at greater risk for hypothermia or frostbite? (select all
that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses
are at greater risk for hypothermia. Clients who smoke, consume
alcohol, or have impaired peripheral circulation have a higher
incidence of frostbite.
The nurse is caring for four clients. Which client
assessment is the most indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision
B
At times clients are unable to verbalize that they are in pain but
there are indicators that the client may have acute pain such as
increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the
other distractors could indicate clients who have the potential for
being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse
educator would explain that informal teaching is an
approach that
,a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which
represents the majority of patient education done by nurses that
occurs when an intervention is explained or a question is
answered. Group needs are often the focus of formal patient
education courses or classes. Informal teaching does not
necessarily follow a specific formalized plan. It may be planned
with specific content, but it is individualized responses to patient
needs. Formal teaching involves the use of a curriculum/course
plan with standardized content.
A patient expresses a strong interest in returning to their
work, family, and hobbies after having a stroke. Which
theory type would the nurse use to develop a plan of care
for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when
integrated, motivate someone to learn. Field theorists place
significance on how achievement, power, the need for affiliation,
and avoidance motives influence individual behavior. Sociologic
theories are not involved in motivation.
Which statement made by a nurse represents the need for
further education regarding pain management in older
adult clients?
a. older adults tend to report pain less often than younger
adults
,b. older clients usually have more experience with pain
than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do
not feel it as much
D
There is no evidence to support the idea that older adult clients
perceive pain any differently than younger clients. The other
statements are accurate regarding older clients and pain.
The nurse is working at a first aid booth for a spring
training game on a hot day. A spectator comes in,
reporting that he is not feeling well. Vital signs are temp
104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood
pressure 106/66 mm Hg. He trips over his feet as the
nurse leads him to a cot. What is the priory action of the
nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical
emergency. The spectator should be transported to the ED ASAP.
The nurs should take actions to lower his body temp in teh
meantime by removing his shirt and sponging his body with cool
water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The
client needs to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium
chloride ina 1000 mL solution of dextrose 5% in 0.45%
saline. The client states that the area around the IV site
burns. What intervention does the nurse perform first?
, a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion
D
Potassium is a severe tissue irritant. The safest action is to
discontinue the solution that contains the potassium and
discontinue the IV altogether, in which case the client would need
another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and
the rate could be slowed once it is determined that the needle is
in the vein.
A nurse is caring for an older adult client who lives alone.
Which economic situation presents the most serious
problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
D
Older adults on fixed incomes are unable to adjust their income to
meet rising costs associated with meeting basic needs
Controlling pain is important to promoting wellness.
Unrelieved pain has been associated with
a. prolonged stress response and a cascade of harmful
effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction
