Nur 215 Mod 4-6 Exam 2
The patient takes anticoagulants. Which instruction is most important for the nurse to
include on the patient's care plan? - answer Use an electric razor shaving
The nurse is caring for a patient admitted with a closed head injury. Which action by the
nurse is appropriate when providing hygiene for this patient? - answer Provide care and
small intervals
A patient has sustained a spinal cord injury and is no longer able to get in and out of the
bathtub without assistance. Which nursing diagnosis appropriately addresses this
problem? - answer Bathing self-care deficit
Which scheduled hygiene care is usually thought of as including a back massage to
help the patient relax? - answer Hour of sleep care
For which patient can the nurse safely delegate morning care to the nursing assistive
personnel? - answer62-year-old who underwent surgical repair of a bowel obstruction
two days ago
The clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate?
- answer Risk for impaired skin integrity
What is the body's first line of defense against bacteria? - answerIntact skin
While bathing a patient with liver dysfunction, the nurse knows yellow skin tone. The
nurse should document this finding as? - answerJaundice
A patient with diarrhea is incontinent liquid stool. The nurse documents that the patient
has excoriated skin on the buttocks. Which finding by the nurse led to this
documentation? - answerSuperficial layers of skin were absent
For which patient problem is it most important to provide frequent perineal care? -
answerActive lower gastrointestinal bleeding
A patient with dementia becomes belligerent when the nurse attempts to give him a tub
bath. How should the nurse proceed? - answerWait for the patient to calm down, and
then give him a towel bath
The nurse is teaching nursing assistive personnel how to give a complete bed bath.
Which instruction should the nurse include? - answerThese the patient from head to toe,
cleanest areas first
, Which actions should the nurse take one preparing a patient for a bed bath? -
answerPlace the nurse called device within reach for safety
A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease
has a nursing diagnosis of activity intolerance. Which type of bath is preferred for this
patient? - answerTowel bath
Wearing poorly fitted shoes may result in which condition? - answerIngrown toenail
The school nurse is teaching a group of middle school students how to prevent tinea
pedis. Which remark by a student provides evidence of learning? - answerI can contract
the infection by walking barefoot in the gymnasiums showers
Bathwater should be prepared at which temperature to prevent chilling and excess
drawing of the skin? - answer105°F (40.6 C)
While assessing a patient, the nurse knows that the patients nails are excessively
brittle. What does this findings suggest? - answerIn adequate dietary intake
A patient with a history of seizures who takes phenytoin is at risk for which oral
problem? - answerGingival hyperplasia
The nurse has been teaching a student how to perform mouth care for her unconscious
patient. The student will show evidence of learning if the patient is placed in which
position? - answerSide lying
Which item is best for providing mouth care for an unconscious patient? - answerFoam
swabs
After receiving a course of chemotherapy, a patient begins losing hair. This adverse
effect of chemotherapy should be documented as? - answerAlopecia
Which statement describes a correct step and removing and cleaning a hearing aid? -
answerClean the top part of the canal portion of the device
The nurse prepares to remove the artificial eye of a patient sitting at the bedside. In
which position should the patient be pleased to facilitate the removal of this device? Ask
the patient to: - answerMove to the bed and lie down
The nurse reviews contact lens care with a client. What statement indicates that the
teaching has been effective? - answerI will use ceiling to clean my lenses
Chapter 31. Sensory perception - answer
The nurse checks a patient's pupils using a penlight. Which receptors is the nurse
stimulating? - answerPhotoreceptors
The patient takes anticoagulants. Which instruction is most important for the nurse to
include on the patient's care plan? - answer Use an electric razor shaving
The nurse is caring for a patient admitted with a closed head injury. Which action by the
nurse is appropriate when providing hygiene for this patient? - answer Provide care and
small intervals
A patient has sustained a spinal cord injury and is no longer able to get in and out of the
bathtub without assistance. Which nursing diagnosis appropriately addresses this
problem? - answer Bathing self-care deficit
Which scheduled hygiene care is usually thought of as including a back massage to
help the patient relax? - answer Hour of sleep care
For which patient can the nurse safely delegate morning care to the nursing assistive
personnel? - answer62-year-old who underwent surgical repair of a bowel obstruction
two days ago
The clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate?
- answer Risk for impaired skin integrity
What is the body's first line of defense against bacteria? - answerIntact skin
While bathing a patient with liver dysfunction, the nurse knows yellow skin tone. The
nurse should document this finding as? - answerJaundice
A patient with diarrhea is incontinent liquid stool. The nurse documents that the patient
has excoriated skin on the buttocks. Which finding by the nurse led to this
documentation? - answerSuperficial layers of skin were absent
For which patient problem is it most important to provide frequent perineal care? -
answerActive lower gastrointestinal bleeding
A patient with dementia becomes belligerent when the nurse attempts to give him a tub
bath. How should the nurse proceed? - answerWait for the patient to calm down, and
then give him a towel bath
The nurse is teaching nursing assistive personnel how to give a complete bed bath.
Which instruction should the nurse include? - answerThese the patient from head to toe,
cleanest areas first
, Which actions should the nurse take one preparing a patient for a bed bath? -
answerPlace the nurse called device within reach for safety
A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease
has a nursing diagnosis of activity intolerance. Which type of bath is preferred for this
patient? - answerTowel bath
Wearing poorly fitted shoes may result in which condition? - answerIngrown toenail
The school nurse is teaching a group of middle school students how to prevent tinea
pedis. Which remark by a student provides evidence of learning? - answerI can contract
the infection by walking barefoot in the gymnasiums showers
Bathwater should be prepared at which temperature to prevent chilling and excess
drawing of the skin? - answer105°F (40.6 C)
While assessing a patient, the nurse knows that the patients nails are excessively
brittle. What does this findings suggest? - answerIn adequate dietary intake
A patient with a history of seizures who takes phenytoin is at risk for which oral
problem? - answerGingival hyperplasia
The nurse has been teaching a student how to perform mouth care for her unconscious
patient. The student will show evidence of learning if the patient is placed in which
position? - answerSide lying
Which item is best for providing mouth care for an unconscious patient? - answerFoam
swabs
After receiving a course of chemotherapy, a patient begins losing hair. This adverse
effect of chemotherapy should be documented as? - answerAlopecia
Which statement describes a correct step and removing and cleaning a hearing aid? -
answerClean the top part of the canal portion of the device
The nurse prepares to remove the artificial eye of a patient sitting at the bedside. In
which position should the patient be pleased to facilitate the removal of this device? Ask
the patient to: - answerMove to the bed and lie down
The nurse reviews contact lens care with a client. What statement indicates that the
teaching has been effective? - answerI will use ceiling to clean my lenses
Chapter 31. Sensory perception - answer
The nurse checks a patient's pupils using a penlight. Which receptors is the nurse
stimulating? - answerPhotoreceptors
