test 3 book

REM sleep25% of night, dreams, 60 mins after sleep begins, average of 20 minsnocturiaurination at nightHypersomnolence Disordersleep dysfunction involving an excessive amount of sleep that disrupts normal routinesHypersomniaexcessive daytime sleepinessNarcolepsyA sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.ptosisblurred vision, sleep deprivation symptomHypnoticsdrugs used to induce sleep. can cause "hangover" feeling during the dayA nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat a large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.1, 4, 5ModafinilCNS stimulant. helps with narcolepsyAntihistaminesused to treat colds and allergiesA 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because prescription medications can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."2Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) 1. Limit fluids 2 to 4 hours before sleep. 2. Ensure that the room is completely dark. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers. 5. Encourage walking an hour before going to bed.1, 3, 4For most persons, how frequently should you remove elastic stockings? A. Once every 8 hours B. Once every 12 hours C. Once every 24 hours D. Once every other dayAAfter removing a person's elastic stockings, how long should you expect to leave them off before reapplying them? A. 30 minutes B. 60 minutes C. 2 hours D. 4 hoursATo which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.B.Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective B. To double-check the size by inserting one finger between the wrist and the restraint C. To check the skin integrity and range of motion of the wrist D. To comply with Joint Commission standardsCWhat would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the patient needs anything for pain."BWhen a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. Check the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the patient's gown C. Put on the call light for help D. Ask the patient what specific help she would likeBhemiparesisweakness on one side of the bodyThe nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? A. Ask the patient how far she would like to go. B. Review the health care provider's order. C. Review the medical record to see how far the patient has walked during the past several therapeutic ambulations. D. Review the records of other patients who are at a similar point in their stroke rehabilitation.AThe nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? A. Slowly lower the patient to the floor. B. Attempt to sit the patient down on a chair just a few steps away. C. Try to hold the patient up until the dizziness passes. D. Call for assistance in a loud but calm voice.AWhen preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? A. Coordinate extra help. B. Assess the patient's vital signs. C. Assess the patient's physiological capacity to transfer. D. Determine whether to transfer the patient to a wheelchair or chair.CA patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? A. Help the patient put on skid-resistant footwear. B. Raise the head of the bed 30 degrees. C. Place the transfer belt over the patient's clothing. D. Position the chair so that the patient will move toward his or her stronger side.BThe nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? A. Place both feet together on the floor. B. Place your weaker foot forward and your stronger leg toward the back. C. Extend both of your legs and feet. D. Place your stronger leg forward and your weaker leg toward the back.DA patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? A. Remove the wheelchair leg rests. B. Ask the patient to rate his or her pain level. C. Lower the foot rests, and place the patient's feet on them. D. Remove the transfer belt.CThe nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A. Four B. Two C. One D. NoneBWhen turning a patient to place a slide board, where do the assistants stand? A. At the side of the bed to which the patient will be turned B. At the side of the bed from which the patient will be turned C. At the head and foot of the bed D. At the foot of the bed onlyAThe nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A. Hold the slide board. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher.A, The nurse, standing alone, will hold the slide board in place as the two assistants pull the draw sheet. The nurse will not hold the patient's head during the move; this action may be performed by an optional assistant.After moving a patient from the bed to a stretcher, what will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the head of the stretcher if doing so is not contraindicated. D. Unlock the wheels of the bed.CWhich restraint alternative could be used to prevent a confused person from wandering into another person's room? A. A floor cushion next to the bed B. A bed or chair alarm C. A padded hip protector D. A knob guard on the doorD. such as a stop signWhich of these devices is a restraint alternative? A. Roll guards that are attached to the bed frame B. Velcro used to hold clothing tight enough to restrict movement C. Bed rails that prevent the person from getting out of bed D. A tray table that blocks the person's freedom of movementAWhich technique is an alternative to restraint use? A. Observe the person at least once every 2 hours B. Discourage visitors because they can cause confusion C. Provide diversions, such as TV, videos, music, and games D. Remove clocks and calendars for a person with confusionCkyphosishunchback. common in older adultsNeck flexion and extension should be: A. 90 degrees B. 70 degrees C. 30 degrees D. 45 degreesd. Neck flexion and extension should each be 45 degrees; rotation should be 70 degrees on each side.What does a goniometer measure? A. Muscle strength B. Joint stability C. Cranial nerve function D. Angles of extension and flexionDWhen preparing to move a patient in bed, what will the nurse do first? A. Assemble adequate help to move the patient. B. Assess the patient's ability to help with moving. C. Determine the patient's weight. D. Decide on the most effective means of moving the patient.BA patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? A. A minimum of two B. None, since the device does all the lifting during the move C. At least three D. The nurse can carry out this move without assistanceCA patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? A. Lift the patient to place the device directly under him or her. B. Remove the drawsheet, and replace it with the device. C. Roll the patient from side to side, and place the device under the drawsheet. D. Sit the patient up in the bed, and place the device behind the shoulders.Ctrochanter rollRolled towel support placed against the hips and upper leg to prevent external rotation of the legs.contracturefibrosis of connective tissue in the skin, fascia, muscle, or joint capsule that prevents normal mobility of the related tissue or jointsupinelying on the backpronelying face downWhen positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? A. To reduce the risk of a fall while the side rails are down B. To reduce the risk of contracture C. To control pain D. To cushion the legsBWhen repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? A. Apply therapeutic boots to the feet. B. Place sandbags along the legs. C. Place a small pillow at the lumbar region of the back. D. Place a pillow under the calves.BThe nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? A. Place a small pillow under the shoulder. B. Use the affected arm as a guide during rolling. C. Place a pillow on the abdomen. D. Place rolled bath blankets along the dependent leg.CA patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? A. Remove the dressing, inspect the wound, and reapply a new dressing. B. Inspect the wound and reapply the surgical dressing every 2 hours. C. Inspect the wound, and keep the dressing off until the health care provider arrives. D. Wait until the health care provider orders the removal of the surgical dressing.DThe nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? A. Osteoarthritis B. Glaucoma C. Deafness D. Diabetes mellitusD, Diabetes decreases tissue perfusion, impairing the supply of oxygen to the tissues.The wound bed of a patient's pressure injury is red. What does this finding indicate to the nurse? A. Necrotic tissue B. Presence of slough C. Granulation tissue D. Development of an infectionCwhat color is granulation tissueredwhat color is slough tissueyellow or graywhat color is a sign of early infection in a woundyellowWhich measurements would the nurse use to calculate the surface area of a patient's pressure injury? A. Height and weight B. Length and width C. Length and depth D. Width and depthBHow would the nurse safely apply an enzyme debridement ointment? A. Daub ointment on dead tissue at the wound edges. B. Put ointment on a tongue blade, and gently spread it on the center of the wound. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. D. Apply a gauze dressing to ensure contact with the ointment.CWhat is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? A. Notify the surgeon of the bleeding. B. Remove the dressing, and assess the wound. C. Assess the patient for signs of shock. D. Further assess the patient and the wound.DWhen irrigating a wound, how would the nurse know the right amount of pressure to apply? A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound.BWhich device is used for wound irrigation? A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. Sterile container held 30.5 cm (12 inches) above the wound D. Foley irrigating syringeBWhich imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient's left heel is infected? A. White blood cell count B. Complete blood count C. X-ray of left foot D. Culture and sensitivity testD. A wound culture and sensitivity test will indicate whether the pressure ulcer is infected, identify the pathogen responsible (if any), and determine which antibiotic the pathogen is most vulnerable to. Although an elevated white blood cell count indicates infection, it would not be specific to the pressure injury in question. The complete blood count cannot indicate or rule out infection.Hemovac drainCLOSED DRAIN SYSTEM, a surgical drain to prevent blood and lymphatic fluid buildup under your skin and encourage healing. drains fluid by passive suctionJackson-Pratt drainhollow bulb-like device used to collect drainageWhat is the proper method for cleansing the evacuation port of a wound drainage system? A. Cleanse it with normal saline. B. Wash it with soap and warm water. C. Rinse it with sterile water. D. Wipe it with an alcohol sponge.DWhat is the nursing action to set up suction for a Hemovac drainage system? A. Set the suction to lowest level possible. B. Hemovacs are always set to medium suction. C. Connect to the wall on intermediate suction. D. Compress the hemovac, creating suction.D. For the Hemovac to create suction, the nurse should compress it firmly and replace the plug. The Hemovac does not need a suction level set. Hemovacs are not set to medium and are not connected to wall suction; they create their own suction when compressed.When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? A. The drainage is odorless. B. The drainage is straw colored. C. The patient doesn't like looking at the drainage tubing. D. The amount of drainage was greater today than yesterday.DWhich action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? A. Pinning the tubing to the patient's hospital gown B. Compressing the bulb while replacing the port cap C. Emptying the drainage container only when it is 90% full D. Placing the drainage container below the wound siteBBarbituratesdrugs that depress the activity of the central nervous system, reducing anxiety but impairing memory and judgmentBenzodiazepinesThe most common group of antianxiety drugs, which includes Valium and Xanax.Melatonin Agonist: Ramelteon-treatment of chronic insomnia characterized by difficulty with sleep onset -only drug not regulated as a controlled substance) -rapid onset (30 mins), short duration -MOA: activates receptors for melatonin Pharmacokinetics -rapid absorption -very low bioavailibity (due to first-pass mechanism) Adverse Effects -somnolnence, dizziness, fatigue -may cause sleep driving / walking No evidence of physical dependence / abuse Precautions: renal impairmentsNonbenzodiazepines-For short term use; not associated with rebound insomnia when discontinued (Zolpidem (Ambien), Zaleplon(Sonata)) -Approved for longer useZolpidem (Ambien)insomniaAlprazolam (Xanax)AntianxietyButabarbital (Butisol)helps with sleep