Nursing 111 Exam 5 Green Book

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  1. A nurse is caring for apatient who is experiencing pain. For which most common psychological patient response to pain should the nurse assess?

    A. Developing an increase tolerance to the drug
    B. Asking for pain medication to relieve the pain
    C. Experiencing fear related to loss of independence
    D. Verbalizing the presence of nausea
    C. Psychological or affective responses to pain relate to feelings and emotional distress. Fear of being dependent on others or loss of self-control are psychological responses to pain.
    (this multiple choice question has been scrambled)
  2. The most appropriate goal for an adult who has disturbed sleep because of nocturia is, "the patient will:

    A. Report fewer early morning  awakenings because of a wet bed."
    B. Demonstrate a reduction in nighttime bathroom visits."
    C. Resume sleeping immediatelu after voiding."
    D. Use an incontinence device at night."
  3. Which concept associated with rest and sleep must the nurse consider when planning nursing care?

    A. Metabolic rates increase during rest
    B. Energy demands increase with age
    C. Sleep requirements increase during stress
    D. Catabolic hormones increase during sleep
  4. A patient has a total abdominal hysterectomy for fourth-stage ovarian cancer. What should the nurse do first when on the second postoperative day this patient reports abdominal pain at level 5 on a 1-to-10 pain scale?

    A. Reposition the patient
    B. Administer the prescribed analgesic
    C. Offer a relaxing back rub
    D. Use distraction techniques
    B. Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision that require adequate pharmacological intervention to provide relief from pain.
    (this multiple choice question has been scrambled)
  5. A patient is diagnosed with narcolepsy. The nurse's primary intervention should address the patient's:

    A. Potential for injury
    B. Impaired thought process
    C. Excessive fatigue
    D. Inability to provide self-care
    A. Narcolepsy is excessive sleepiness in the daytime that can cause a person to fall asleep uncontrollably at inappropriate times (Sleep Attack) and result in physical harm to self or others.
    (this multiple choice question has been scrambled)
  6. A nurse is caring for a patient who is having difficulty sleeping. Which patient response indicates to the nurse that the patient is not obtaining adequate rapid-eye-movement (REM) sleep?

    A. Vertigo
    B. Immunosuppression
    C. Irritability
    D. Hyporesponsiveness
    C. Rapid-eye-movement (REM) sleep is essential for maintaining mental and emotional equilibrium and, when interrupted, results in irritability, excitability, restlessness, confusion, and suspiciousness.
    (this multiple choice question has been scrambled)
  7. A patient is experiencing discomfort associated with gastroesophageal reflux. In which position should the nurse teach the patient to sleep?

    A. Semi-Fowler
    B. Right Lateral
    C. Prone
    D. Sims

    A. The extent of pain is directly related to the amount of tissue damage
    B. Administering opioids for pain will eventually lead to addiction
    C. Behavioral adaptions are congruent with statements about pain
    D. The person experiencing the pain is the authority about the pain
    D. Pain is a personal experience. Margo McCaffery, a pain researcher, has indicated that pain is whatever the person in pain says it is and exists whenever the person in pain says it exists.
    (this multiple choice question has been scrambled)
  9. A patient is experiencing anxiety. Which aspect of sleep should the nurse expect will be affected as a result of the anxiety?

    A. Duration
    B. Stage II
    C. Depth
    D. Onset
    D. Anxiety increases norepinephrine blood levels through stimulationof the sympathetic nervous system, which results in prolonged sleep onset.
    (this multiple choice question has been scrambled)
  10. A patient requests pain medication. What should the nurse do first when responding to this patient's The nurse is planning a teaching program

    A. Use distraction to minimize the patient's perception of pain
    B. Assess the various aspects of the patient's pain
    C. Place the patient in the most comfortable position possible
    D. Administer pain medication to the patient quickly
    B. All the factors that affect pain experience should be assessed, including location, intensity, quality, duration, pattern, aggravating and alleviating factors, and physical, behavioral, and attitudinal responses. Assessment must precede intervention.
    (this multiple choice question has been scrambled)
  11. The nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which is the most common intervention that the nurse should plan to discuss with this patient?

    A. Encouraging sleeping in the supine position
    B. Using devices that support airway patency
    C. Positioning two pillows under the head
    D. Administering sedatives
  12. Which statement by the patient to a nurse indicates a precipitating factor associated with pain?

    A. "My pain feels like a knife cutting right through me." 
    B. "I usually feel a little dizzy and think I'm going to vomit when I have pain."
    C. "I usually have pain after I get dressed in the morning."
    D. "My pain usually comes and goes throughout the night."
    C. Anything that induces or aggravates pain is considered a precipitating factor of pain. For example, precipitating factors may be physical (e.g. exertion associated with activities of daily living, valsalva maneuver) environmental (e.g. extremes in temperature, noise), or emotional (anxiety,fear).
    (this multiple choice question has been scrambled)
  13. Which is the most important nursing intervention that supports a patient's ability to sleep in the hospital setting?

    A. Providing an extra blanket
    B. Limiting neccessary noise on the unit
    C. Shutting off lights in the patient's room
    D. Pulling curtains around the bed at night
    B. Noise is serious deterrent to sleep in a hospital. The nurse should limit environmental noise (ex. distributing fluids, providing treatments, rolling drug and lining carts) and staff communication noise.
    (this multiple choice question has been scrambled)
  14. A patient has a history of severe chronic pain. Which is one of the most important guidelines associated with providing nursing care to this patient?

    A. Asking what is an acceptable level of pain
    B. Providing interventions that do not precipitate pain
    C. Determine the level of function that can be performed without pain
    D. Focusing on pain management intervention before pain becomes excessive
  15. What concept should the nurse consider when assessing a patient's pain?

    A. The expression is not always congruent with the pain experienced
    B. Pain medication can significantly increase a patient's pain tolerance
    C. The majority of cultures value the concept of suffering in silence
    D. Most people experience approximately the same pain tolerance
  16. Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care?

    A. Fragmented sleep
    B. Early awakening
    C. Restless legs
    D. Sleep apnea

    A. "I try to pretend that it is not part of me, but it takes a lot of effort."
    B. "My pain medication works, but I'm afraid of becoming addicted."
    C. "At home I take something for the pain before it gets to bad."
    D. "They say my pain may get worse, and I can't stand it now."
  18. A patient has been in the Intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the patient?

    A. Hypoxia
    B. Delirium
    C. Lethargy
    D. Dementia
  19. What concept associated with sleep should the nurse consider to best plan nursing care for a hospitialized patient?

    A. People require eight hours of uninterrupted sleep to meet energy needs
    B. Frequency of nighttime awakenings decreases with age
    C. Fear can contribute to the need to stay awake
    D. Bed rest decreases the need for sleep
  20. A nurse is assessing a patient in pain. What word might the nurse use when documentating the pattern of a patient's pain?

    A. Tenderness
    B. Moderate
    C. Phantom
    D. Episode
  21. A nurse is obtaining a health history from a newly admitted patient. Which patient statement about alcohol intake in based on a common physiological response?

    A. "After I go drinking, I have to urinate during the night."
    B. "When I drink, I get hungry in the middle of the night."
    C. "Falling asleep is hard, but once asleep I sleep great."
    D. "If I drink too much, I oversleep in the morning."
  22. A nurse is assessing a patient experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain?

    A. Self-focusing
    B. Sleep disturbances
    C. Guarding behaviors
    D. Variations in Vital Signs
  23. Preemptive analgesia is used when a nurse medicates the patient:

    A. Before the patient goes to sleep
    B. As soon as the patient complains of pain
    C. At equal distant times around the clock
    D. Before doing a dressing change that has been painful in the past
  24. A patient is diagnosed with chronic fatigue syndrome. It is most important that the nurse explore the extent of the patient's:

    A. Ability to provide self-care
    B. Physical Mobility
    C. Social Isolation
    D. Gas exchange
  25. When caring for patients in pain, it is important for the nurse to consider that patients:

    A. Are able to describe the qualities of their pain
    B. Who are in pain will request pain medication
    C. Need to know that the nurse believes what they say about their pain
    D. Will demonstrate vital signs that are congruent with the intensity of the pain
  26. A patient is experiencing interrupted sleep. For which is response associated with shortened non-rapid-eye-movement (NREM) sleep should the nurse assess the patient?

    A. Anxiety
    B. Hyperactivity
    C. Delayed Healing
    D. Aggressive behavior
  27. A patient is experiencing lack of sleep because of pain. Which is most appropriate goal for this patient? "The patient will:

    A. Be provided with a back massage every evening before bedtime."
    B. Report feeling rested after awakening in the morning."
    C. Request less pain medication during the night."
    D. Experience four hours of uninterrupted sleep."
  28. A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective?

    A. Assisting with relaxing imagery
    B. Obtaining a prescription for an opioid
    C. Encouraging the patient to take a warm shower
    D. Recommending that the patient be more active during the day

    A. 12 noon and 2 pm
    B. 6 am and 8 am
    C. 2 am and 4 am
    D. 6 pm and 8 pm
  30. Which patient statement indicates that the patient is experiencing bruxism?

    A. "I walk around in my sleep almost every night, but I don't remember it."
    B. " I annoy the whole family will the loud snoring noises I make at night."
    C. " I occasionally urinate in bed when I am sleeping, and it's embarrassing."
    D. " I am only told by my wife that I make a lot of noise grinding my teeth when I sleep."
  31. A patient is having difficulty sleeping and my be experiencing shortened NREM sleep. What patient assessment supports this conclusion?

    A. Decreased Pain Tolerance
    B. Excessive sleepiness
    C. Confusion
    D. Irritability
  32. A nurse is caring for patients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action?

    A. Patient-Controlled Analgesia
    B. Intramuscular sedatives
    C. Intravenous Narcotics
    D. Regional Anesthesia
  33. A nurse is teaching a community health education class about rest and sleep. Which concept related to sleep should the nurse include?

    A. Bedtime routines are associated with an expectation of sleep
    B. Alcohol intake interferes with one's ability to fall asleep
    C. Sleep needs remain consistent throughout the life span
    D. Total time in bed gradually decreases as one ages
  34. A nurse is teaching a patient various techniques to promote sleep. What internal stimulus that most commonly interferes with sleep should the nurse include in the teaching?

    A. Ringing in the ears
    B. Bladder Fullness
    C. Hunger
    D. Thirst
  35. A nurse is giving a back rub. What stroke is most effective in inducing relaxations at the end of the procedure?

    A. Percussion
    B. Effleurage
    C. Kneading
    D. Circular
  36. A patient states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement?

    A. Pattern
    B. Duration
    C. Location
    D. Constancy
  37. A nurse is providing health teaching for a patient with the diagnosis of obstructive sleep apnea. Which aspect of sleep should the nurse explain is most often affected?

    A. Amount
    B. Quality
    C. Depth
    D. Onset
  38. A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic open-ended question the nurse can ask about the quality of the patient's sleep?

    A. "How would you describe your sleep."
    B. "Do you consider your sleep to be restless or restful?"
    C. "Is the number of hours you sleep at night good for you?"
    D. "Does your bed partner complain about your sleep behaviors?"
  39. When assessing patients who have a difficulty sleeping, the nurse considers that there are common psychological and physiological responses to insomnia. Select all those that are physiological responses to insomnia.

    • Vertigo
    • Fatigue
    • Headache
  40. A practitioner prescribes oxycodone oral solution 15 mg every 6 hours. The drug is supplied in a 500 ml bottle that indicates 5 mg/5ml.How much oral solution should the nurse administer?
    15 mL

    5mL/5mg x 15mg/1 = 75/5= 15
Card Set
Nursing 111 Exam 5 Green Book
Nursing Test 5 Sleep, Comfort, Rest,Pain, Death and Dying
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