NUR 215 Exam 2 A
It is most important for the nurse to understand the various ways in which pain is
classified so that he or she can
A. Document the client's pain using accurate terms.
B. Be clear in communication with the physician.
C. Develop an effective pain management plan.
D. Educate the client thoroughly. - answerC: Develop an effective pain management
plan
Different modalities are used in the treatment/ management of pain and are often based
on how the pain is classified (e.g., acute versus chronic).
The nurse is assessing the confused client. In trying to determine the client's level of
pain, the nurse should
A. Be aware that confused clients do not feel as much pain due to their confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client's family how much pain the client normally has.
D. Use only pain scales that feature numbers or "faces" the client can point to. -
answerB. Observe the client carefully for changes in behavior or vital signs.
The nurse should observe the confused client for nonverbal cues to pain.
Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health
nurse what can be done. In relation to his long-acting opioid, which is an appropriate
response by the nurse?
A. "If you take more opioid, it will not change your pain relief."
B. "I'll call the primary care provider and ask for an increased dose."
C. "The amount you are taking now is all I can give you."
D. "I'm worried if we increase your dose that you will stop breathing." - answerB. "I'll call
the primary care provider and ask for an increased dose."
There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a
tolerance to the effects, which often necessitates an increase in the dose.
To maintain proper posture, it is important to
A. Sleep on the softest mattress possible.
B. Avoid arching shoulders forward when sitting.
C. Keep your knees locked when standing upright.
,D. Keep your stomach muscles relaxed to prevent back spasms. - answerB. Avoid
arching shoulders forward when sitting.
Arching shoulders forward when sitting alters the curvature of the spine and contributes
to poor body alignment.
Of the following interventions for the client who is immobile, the nurse will give priority to
A. Encouraging a diet high in fiber and extra fluids
B. Administering the medication for sleep as needed
C. Having the client use the incentive spirometer q 2 hrs
D. Massaging the client's legs every hour - answerC. Having the client use the incentive
spirometer q 2 hrs
Use of the incentive spirometer helps to prevent atelectasis, which improves
oxygenation—a priority need.
Identify the true statement about devices used when assisting clients to ambulate.
A. The client should stand a foot back from the back legs of a walker.
B. A cane should be used by the client to support the weakest side of the body.
C. A transfer belt should be placed around the client's chest for maximum lift.
D. Each crutch-walking gait begins with the client in the tripod position. - answerD. Each
crutch-walking gait begins with the client in the tripod position.
The tripod position is the basic crutch standing position from which the client then
moves forward.
A name-brand ice cream contains the following nutrition information for each serving: 30
g carbohydrates, 19 g fat, 5 g protein. The total number of calories in a serving would be
A. 366
B. 311
C. 435
D. 176 - answerB. 311
CHO = 4 cal per gram = 120 cal
Fat = 9 cal per gram = 171 cal
Protein = 4 cal per gram = 20 cal
Total: 311 cal
Identify the client with the greatest risk for developing protein-calorie malnutrition.
A. A client who has multiple sclerosis and is in a wheelchair
B. A client weighing 300 lb who has entered the hospital for cardiac bypass surgery
, C. A client with a broken arm and femur from trauma who is running a fever of 101.5°F
(38.6°C)
D. A client who is of Native American heritage - answerC. A client with a broken arm
and femur from trauma who is running a fever of 101.5°F (38.6°C)
This client would have the greatest increase in metabolic demand for "energy"/nutrients
and runs the greatest risk for not having those energy demands met.
The nurse knows the lab result that is the best indicator of a client's nutritional status is
the serum albumin.
A. True
B. False - answerB. False
The latest research shows that prealbumin has a shorter half-life than albumin and is a
better indicator of protein stores (and acute changes in those stores).
Which factor would be most likely to influence the hygiene practice of the homeless
client?
A. The client's degree of mental illness
B. The client's cultural beliefs
C. The client's living environment
D. The client's knowledge level - answerC. The client's living environment
The homeless client may have no access to facilities in which to perform routine
hygiene measures.
The confused client becomes distressed and agitated when the U A P attempts to give
the morning bath. The nurse instructs the U A P to complete a
A. Partial bath
B. Assist bath
C. Bed bath
D. Complete bath - answerA. Partial bath
The intent of the partial bath is to cleanse only the areas in most need of hygienic care.
The nurse would continue to monitor the client's emotional/cognitive status and alter the
type of bath accordingly.
When providing oral care for the unconscious patient, the nurse should
A. Place the patient on his or her side with the head of the bed in a lowered position.
B. Skip brushing the teeth as the patient could aspirate.
C. Swab the patient's lips and oral cavity with lemon glycerin swabs at least hourly.
It is most important for the nurse to understand the various ways in which pain is
classified so that he or she can
A. Document the client's pain using accurate terms.
B. Be clear in communication with the physician.
C. Develop an effective pain management plan.
D. Educate the client thoroughly. - answerC: Develop an effective pain management
plan
Different modalities are used in the treatment/ management of pain and are often based
on how the pain is classified (e.g., acute versus chronic).
The nurse is assessing the confused client. In trying to determine the client's level of
pain, the nurse should
A. Be aware that confused clients do not feel as much pain due to their confusion.
B. Observe the client carefully for changes in behavior or vital signs.
C. Ask the client's family how much pain the client normally has.
D. Use only pain scales that feature numbers or "faces" the client can point to. -
answerB. Observe the client carefully for changes in behavior or vital signs.
The nurse should observe the confused client for nonverbal cues to pain.
Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health
nurse what can be done. In relation to his long-acting opioid, which is an appropriate
response by the nurse?
A. "If you take more opioid, it will not change your pain relief."
B. "I'll call the primary care provider and ask for an increased dose."
C. "The amount you are taking now is all I can give you."
D. "I'm worried if we increase your dose that you will stop breathing." - answerB. "I'll call
the primary care provider and ask for an increased dose."
There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a
tolerance to the effects, which often necessitates an increase in the dose.
To maintain proper posture, it is important to
A. Sleep on the softest mattress possible.
B. Avoid arching shoulders forward when sitting.
C. Keep your knees locked when standing upright.
,D. Keep your stomach muscles relaxed to prevent back spasms. - answerB. Avoid
arching shoulders forward when sitting.
Arching shoulders forward when sitting alters the curvature of the spine and contributes
to poor body alignment.
Of the following interventions for the client who is immobile, the nurse will give priority to
A. Encouraging a diet high in fiber and extra fluids
B. Administering the medication for sleep as needed
C. Having the client use the incentive spirometer q 2 hrs
D. Massaging the client's legs every hour - answerC. Having the client use the incentive
spirometer q 2 hrs
Use of the incentive spirometer helps to prevent atelectasis, which improves
oxygenation—a priority need.
Identify the true statement about devices used when assisting clients to ambulate.
A. The client should stand a foot back from the back legs of a walker.
B. A cane should be used by the client to support the weakest side of the body.
C. A transfer belt should be placed around the client's chest for maximum lift.
D. Each crutch-walking gait begins with the client in the tripod position. - answerD. Each
crutch-walking gait begins with the client in the tripod position.
The tripod position is the basic crutch standing position from which the client then
moves forward.
A name-brand ice cream contains the following nutrition information for each serving: 30
g carbohydrates, 19 g fat, 5 g protein. The total number of calories in a serving would be
A. 366
B. 311
C. 435
D. 176 - answerB. 311
CHO = 4 cal per gram = 120 cal
Fat = 9 cal per gram = 171 cal
Protein = 4 cal per gram = 20 cal
Total: 311 cal
Identify the client with the greatest risk for developing protein-calorie malnutrition.
A. A client who has multiple sclerosis and is in a wheelchair
B. A client weighing 300 lb who has entered the hospital for cardiac bypass surgery
, C. A client with a broken arm and femur from trauma who is running a fever of 101.5°F
(38.6°C)
D. A client who is of Native American heritage - answerC. A client with a broken arm
and femur from trauma who is running a fever of 101.5°F (38.6°C)
This client would have the greatest increase in metabolic demand for "energy"/nutrients
and runs the greatest risk for not having those energy demands met.
The nurse knows the lab result that is the best indicator of a client's nutritional status is
the serum albumin.
A. True
B. False - answerB. False
The latest research shows that prealbumin has a shorter half-life than albumin and is a
better indicator of protein stores (and acute changes in those stores).
Which factor would be most likely to influence the hygiene practice of the homeless
client?
A. The client's degree of mental illness
B. The client's cultural beliefs
C. The client's living environment
D. The client's knowledge level - answerC. The client's living environment
The homeless client may have no access to facilities in which to perform routine
hygiene measures.
The confused client becomes distressed and agitated when the U A P attempts to give
the morning bath. The nurse instructs the U A P to complete a
A. Partial bath
B. Assist bath
C. Bed bath
D. Complete bath - answerA. Partial bath
The intent of the partial bath is to cleanse only the areas in most need of hygienic care.
The nurse would continue to monitor the client's emotional/cognitive status and alter the
type of bath accordingly.
When providing oral care for the unconscious patient, the nurse should
A. Place the patient on his or her side with the head of the bed in a lowered position.
B. Skip brushing the teeth as the patient could aspirate.
C. Swab the patient's lips and oral cavity with lemon glycerin swabs at least hourly.
