306 - Test 3
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- The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?
- b.Activity intolerance related to pain
- The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. The nurse should:
- c. Assist the client to obtain the necessary information to make this decision
- A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, "I wonder why this happened to me?" According to Kubler-Ross, the nurse identifie
- b. denial
- The nurse is using Bowlby's phases of mourning as a framework for assessing the client's response to the traumatic loss of her leg. During the "yearning and searching" phase, the nurse anticipates that the client may respond by:
- a.Crying off and on
- The nurse is completing an assessment on the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is:
- d."Do you snore loudly or experience headaches?"
- For a client who is currently taking a diuretic, the nurse should inform the client that he or she may experience:
- a. Nocturia
- Which of the following information provided by the client's bed partner is most associated with sleep apnea?
- d. excessive snoring
- With advancing age, which of the following normal physiological changes in sensory function occurs?
- d. Decreased sensitivity to pain
- The client has hyperesthesia apparently associated with a neurologic trauma. Which of the following is an appropriate nursing intervention in regard to the client's sense of touch?
- b.Keeping the client loosely covered with sheets and blankets
- The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:
- c. Using a picture chart for the client's responses
- the 24 hour, day-night cycle (also known as the diurnal)
- Circadian rhythm
- primary disorders that have their origin in different body systems and are subdivided into three major groups: intrinsic, extrinsic, and circadian rhythm disorders
- dyssomnias
- undesirable behaviors that occur predominantly during sleep
- parasomnias
- the physiology of sleep is complex. which of the following is the most appropriate statement in regard to this process?
- c. the reticular activating system is partly responsible for the level of consciousness of a person
- it is determined that the client will need pharmacologic treatment to assist with his sleeping patterns. the nurse anticipates that treatment with an antianxiety-reducing, relaxation-promoting medication will include the use of:
- c. benzodiazepines
- Stage 1: NREM
- lightest level of sleep, lasts a few minutes, gradual fall in vital signs, person is easily aroused
- Stage 2: NREM
- period of sound sleep, relaxation progresses, lasts 10-20 minutes, arousal remains relatively easy
- Stage 3: NREM
- initial stages of deep sleep, person rarely moves, muscles are completely relaxed, lasts 15-30 minutes
- Stage 4: NREM
- deepest stage of sleep, very difficult to arouse sleeper, if sleep loss has occured, sleeper will spend considerable portion of night in this stage, lasts approximately 15-30 minutes, sleepwalking may occur
- REM sleep
- vivid, full color dreaming may occur, stage usually begins about 90 minutes after sleep has begun, gastric secretions increase, very difficult to arouse sleeper, duration increases with each cycle and averages 20 minutes
- sense of knowing where your body is
- kinesthetic
- extreme sensitivity to touch
- hyperesthesia
- difficulty understanding language
- receptive aphasia
- knowing how parts of your body are functioning from the inside
- proprioceptive
- difficulty naming common objects
- expressive aphasia
- language center
- temporal lobe
- diabetic retinopathy
- #1 cause for blindness
- xerostomia
- lack of taste, tongue becomes dry
-
Kubler Ross Stages of death and dying:
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> - 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
- Bowlby's theory of Grief - phases of mourning
- 1. Numbing 2. Yearning and Searching 3. Disorganization and despair 4. Reorganization
- Worden's theory of grief - four tasks of mourning
- 1. task I - accept reality of loss 2. task II - work through the pain of grief 3. task III - adjust to the environment in which deceased is missing 4. task IV - emotionally relocate the deceased; move on with life
- Complicated Grief:
- 1. chronic grief 2. delayed grief 3. exaggerated grief 4. masked grief
- deals with expression of feelings and acceptance of attitudes, opinions, or values.
- affective learning
- a concept included in social learning theory refers to a person's perceived ability to successfully complete a task
- self-efficacy
- 7 subsets of psychomotor learning:
- 1. perception 2. set -- readiness to take action 3. guided response 4. mechanism 5. complex overt response 6. adaptation 7. origination
- somatic pain
- bone, joint, muscle, skin, or connective tissue
- WILD (acute) SCARF (chronic)
- When does the pain occur Intensity of the pain Location of the pain Duration of the pain queality of Sleep ability to Concentrate affect Activity level Relationships influence Functioning/Fatigue