Which physical assessment of the skin indicates that a client is addicted to phencyclidine? - ANS-
*Red and dry skin is associated with phencyclidine abuse*.
A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse.
Diaphoresis is associated with chron...
Nursing Sciences - EAQ's JG OG - Part II Exam
Review 2024-2025
Which physical assessment of the skin indicates that a client is addicted to phencyclidine? - ANS-
*Red and dry skin is associated with phencyclidine abuse*.
A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse.
Diaphoresis is associated with chronic abuse of sedative hypnotics.
What is the most important skill of the nurse leader? - ANS- The most important leadership skill for a
nursing student is clinical care coordination. Priority setting, time management, and clinical decision-
making are secondary components included in clinical care coordination.
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which
problem associated with anesthetic agents? - ANS- After abdominal or pelvic surgery clients are at
risk for **paralytic ileus** as a result of receiving an anesthetic agent. The nurse can prevent or
minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions
such as turning and early ambulation. Evidence of bowel function returning to normal includes
auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic
reflux are not postoperative complications related to anesthetic agents.
Which therapeutic communication technique involves using a coping strategy to help the nurse and
client adjust to stress? - ANS- **Sharing humor** is a therapeutic communication technique that
involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress.
Which critical thinking skill does the nurse associate with the concept of maturity? - ANS- Maturity is
the *ability of a critical thinker to reflect on his or her own judgments*
Which psychophysiologic factors can influence communication between a nurse and a client? Select
all that apply. - ANS- *Growth and development* and
*emotional status*
are two psychophysiologic factors that influence communication between a nurse and a client.
,R: Privacy level is an environmental factor. Information exchange is a situational factor. Level of
caring expressed is a relational factor.
Nursing actions for an older adult should include health education and promotion of self-care. Which
is most important when working with an older adult client? - ANS- Reinforcing the client's strengths
and promoting reminiscing
R: Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life
review that assists adaptation and helps achieve the task of integrity associated with older
adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may
enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should
be encouraged; increasing calories may cause obesity.
Which statement is true for attachment in the newborn? - ANS- Attachment is the interaction
between the parent and child. The nurse promotes the parents' and newborn's need for physical
contact by encouraging breast feeding. Attachment is a process that evolves over the first 24
months. The newborn is awake and alert for the first half-hour after birth, during which parent-child
interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns
that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the
maternal pelvis during birth.
When planning discharge teaching for a young adult, the nurse should include the potential health
problems common in this age group. What should the nurse include in this teaching plan? - ANS-
Accidents including thier prevention
R: Accidents are common during young adulthood because of immature judgment and impulsivity
associated with this stage of development. Kidney dysfunction is not a problem specific to any one
stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma
is a common health problem in older adults.
Which intrinsic factor is associated with the fall of an older adult? - ANS- Intrinsic risk factors
associated with the fall of an older adult may include **deconditioning**. Wet floors, poor lighting,
and inappropriate footwear are extrinsic risk factors.
A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be
appropriate to include in the instructions? - ANS- You will need to apply them in the morning before
you lower your legs from the bed to the floor."
, R: Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor
prevents excessive blood from collecting and being trapped in the lower extremities as a result of
the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi,
especially in clients who have had surgery or who have limited mobility, by applying constant
compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night,
rolled down, or applied after the legs are lowered to the floor.
The nurse must understand the process of changing behaviors to be able to support difficult
behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by
DiClemente and Prochaska (1998) in the transtheoretical model of change. - ANS- Precontemplation
contemplation
preparation
action
maintenance stage
The first stage of behavioral change - ANS- the *precontemplation stage*. During this stage, the
client may be defensive when confronted with information about the behavior. The client does not
intend to make any changes within the next six months.
The second stage of behavioral change - ANS- The second stage is the *contemplation stage*. The
client begins to consider a change within the next six months as he or she develops more belief in
the value of change.
The 3rd stage of behavioral change - ANS- The third stage is *preparation* when the client believes
that advantages outweigh disadvantages of behavior change. The client needs assistance planning
for a change in the next month.
4th Stage of Behavior Change - ANS- The fourth stage is *action*, which will last up to six months.
During this stage the client is actively engaged in strategies to change behavior while the nurse
identifies barriers to change.
5th Stage of Behavior Change - ANS- The fifth stage is the *maintenance stage*, which begins six
months after the change has started and continues indefinitely.
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