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WorksheetsPain, sleep and H2T's
Total questions: 15
Worksheet time: 8mins
Check all appropriate nursing measures to promote restorative sleep in a critically ill patient.
Dim the lights and close the door
Encourage the patient to get some exercise
Refrain from waking the patient for nursing care
Silence alarms on equipment
Provide medical pain relief before bedtime
Pain felt in the left arm/shoulder from a possible MI is referred to as :
referred pain
radiating pain
acute pain
intractable pain
what are the risk factors associated with not getting adequate and restorative sleep? check all that apply
healing is slow and incomplete
decreased immunity
increased accidents
pain tolerance increase
work performance suffers
Which of the following nursing interventions demonstrates therapeutic nursing care to a patient with chronic pain?
not medicating the patient with narcotics
Verbalizing acknowledgment of the patient's pain
Instruct patient to report developing/recurrent pain and not wait until pain is severe (for prn pain med)
weaning patient off pain medication
If a patient is eupneic, this means that respirations are:
between 20 and 24 per mn and the patient is using thoracic muscles
require the use of accessory muscles
very shallow and at a rate between 8-12 per min
are considered to be normal in depth and rate with use of the abdominal muscles
The correct assessment sequence of the abdomen is as follows.
inspection, auscultation, palpation
inspection, palpation, auscultation
palpation, inspection, auscultation
auscultation, palpation, inspection
A patient is admitted with a dx of a stroke. She becomes frustrated because she is unable to respond verbally to the nurse's questions. This will be charted as:
dysphagia
aphasic
dysphasia
dyspneic
How would you document respirations that are regular, however they are abnormally deep and rapid.
Cheyne-Stokes
bradypnea
biot
Kussmauls
Post-operatively, a patient who has had knee replacement surgery exhibits slurred speech and c/o moderate pain, what is an appropriate nurse measure
calls the dr immediately because she is having a stroke due to a blood clot that traveled from her legs post-op
instructs the patient to let the nurse know if the pain or the slurred speech gets worse, then reassess the patient in 4 hours
check the patient's chart to determine whether the slurred speech can be attributed to post-op medications. if not, summons MD to determine she is having post-op complications
ask the dr to adjust the patient's pain meds to relieve the pain and prevent any further slurring of speech
What can be detected through palpation?
distension of bladder
skin turgor
edema
hyperinflated lungs
pain
If a patient needs to perform a neurological assessment on a patient who is difficult to rouse, the nurse may correctly..
slap the patient
press on a nailbed
perform a sternal rub
turn up the volume on the tv
check all the following that is assessed in a focused assessment of the cardiovascular system every 4 hours
blood pressure and pain
skin color,moisture and temp
edema
color of nailbeds
JVD is a sign of?
dehydration
fluid overload
edema
gingivitis
Check all nonverbal behaviors indicative of a patient experiencing pain.
clenching
ataxia
grimacing
restlessness
How are EOMs assessed?
By having the patient balance on one foot
by having the patient follow your pen in the 6 cardinal directions with their eyes without moving their head
By having the patient focus on an object nearby and then far away
by shining pen light in one eye and then the other looking for pupil constriction
