Nursing Acceleration Challenge Exam
(NACE) I PN-RN: Foundations of Nursing
Practice Test 2023
An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet
basic standards for hygiene, how frequently should the patient be bathed?
Biweekly
Weekly
Two to three times we...
Nursing Acceleration Challenge Exam (NACE) I PN -RN: Foundations of Nursing Practice Test 2023 An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet basic standards for hygiene, how frequently should the patient be bathed? Biweekly Weekly Two to three times weekly Daily - Correct answer -Two to three times weekly While adults don't usually need daily baths, they should bathe two to three times weekly. Grab bars, shower or tub seats, tub mats, handheld showers, and proper heating (to avoid chilling the patient) can facilitate more frequent bathing. Mild soap and bath oi l may reduce the drying of skin. Patients who are fearful of tubs and showers, common with dementia, may receive a sponge bath or Comfort Bath with premoistened, warmed washcloths. Thick -handled toothbrushes or electric toothbrushes may facilitate mouth ca re. At which time of day are patients with cognitive impairment usually MOST sensitive to sensory overload? Late evening Noon Afternoon Early morning - Correct answer -Afternoon Many people are more sensitive to sensory overload in the afternoon when corti sol levels are highest. Sensory overload most often affects those with cognitive impairment or those in stressful situations. Excess noise and activity can cause distress, agitation, confusion, and delirium. Sensory deprivation occurs when there is too lit tle environmental stimulation because of reduction in sensory input because of hearing or vision deficits, inability to recognize sensory input because of cognitive impairment, or a boring environment. Sensory deprivation can contribute to confusion, disor ientation, and depression. Which of the following is characteristic of nociceptive pain? Burning, stabbing, or shooting pains Diffuse or cramping pain Acute aching or throbbing pain localized to the site of injury Association with chronic conditions such as diabetes or cancer - Correct answer -Acute aching or throbbing pain localized to the site of injury Nociceptive pain usually correlates with the extent and type of injury: the greater the injury, the greater the pain. It may be procedural pain (related t o wound manipulation and dressing changes) or surgical pain (related to the cutting of tissue). It may also be continuous or cyclic, depending upon the type of injury. This type of pain, often described as aching or throbbing, is usually localized to the a rea of injury and resolves over time as healing takes place, and it usually responds to analgesia. According to the three -step World Health Organization (WHO) "analgesic ladder," a patient complaining of moderate to severe pain unresponsive to NSAIDs may require which of the following medications? Morphine Demerol Codeine Acetaminophen - Correct answer -Codeine Step 1: Mild to moderate pain is treated with aspirin, acetaminophen, and NSAIDs. Step 2: Moderate to severe pain unrelieved by Step 1 medications m ay need opioids, such as codeine, tramadol, or Percocet. Step 3: Severe pain without relief from Step 1 or Step 2 medications may need stronger opioids, such as morphine, Dilaudid, or MS -Contin Which type of precautions is indicated for a patient with a surgical -site infection and purulent discharge? Contact and droplet Airborne Droplet Contact - Correct answer -Contact Which of the following injection sites is the BEST choice for intramuscular ( IM) administration of 3 mL of medication for a well -developed adult female of normal weight? Deltoid Vastus lateralis Dorsogluteal site Ventrogluteal site - Correct answer -Ventrogluteal site The ventrogluteal site is the preferred IM injection site because there is little danger of injecting into fatty tissue, large nerves, or blood vessels. In a well -developed adult, up to 4 mL can be safely injected. The dorsogluteal site is the least preferred site because of its proximity to the sciatic nerve and large blood vessels and increased fat deposits. The vastus lateralis site is also good because it lacks large nerves or large blood vessels. The deltoid site is usually avoided because of the small muscle size and the proximity of the radial nerve and artery. In jections to the deltoid should be limited to 1 mL. A burn patient is upset and argues loudly with the nurse, refuses wound care, and states that the treatment is too painful. Which response is an example of therapeutic communication? "You should be happy that the burns are healing so well" "You should stop arguing with the nurses" "Everyone gets upset at times"
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