Week 2

Question 1

What is the nurse’s priority when performing a pain assessment?

Answer 1

Use a reliable, valid pain scale and accept the client’s self-report.

Question 2

Acute pain is defined as lasting how long?

Answer 2

Less than 6 months.

Question 3

Chronic pain lasts how many months or longer?

Answer 3

6 months or longer.

Question 4

Which physiological change occurs with severe unrelieved pain?

Answer 4

Decrease in BP and HR due to sympathetic exhaustion.

Question 5

What does the ‘P’ in PQRST stand for?

Answer 5

Provocation or precipitating factors.

Question 6

Which scale uses cartoon faces to help pediatric clients rate pain?

Answer 6

Wong-Baker FACES Scale.

Question 7

Give two objective indicators of pain.

Answer 7

Restlessness, guarding, grimacing, elevated BP/HR initially.

Question 8

How should a nurse educate a patient receiving opioids at home.

Answer 8

Use lowest effective dose; monitor for respiratory depression and constipation.

Question 9

Which pain medication class increases risk of GI bleeding?

Answer 9

NSAIDs (non-opioid).

Question 10

What teaching is essential for a patient with a PCA pump?

Answer 10

Only the patient should press button; report dizziness or low O₂.

Question 11

Give three non-pharmacologic interventions for mild pain.

Answer 11

Heat/cold therapy, massage, distraction.

Question 12

Example of referred pain?

Answer 12

Jaw pain during myocardial infarction.

Question 13

Which pain type results from tendon or ligament damage?

Answer 13

Somatic pain.

Question 14

Which pain type originates from internal organs?

Answer 14

Visceral pain.

Question 15

Why should nurses assess cultural beliefs in pain management?

Answer 15

Culture influences how patients express and cope with pain.

Question 16

Hygiene is primarily aimed at preventing what?

Answer 16

Spread of pathogens and HAIs.

Question 17

What is the body’s first line of defense against infection?

Answer 17

The integumentary system (skin, hair, nails).

Question 18

The skin’s Langerhans cells function to what?

Answer 18

Detect and destroy pathogens.

Question 19

What is the outermost skin layer?

Answer 19

Epidermis.

Question 20

What is the subcutaneous layer called?

Answer 20

Hypodermis; provides cushioning and fat storage.

Question 21

When is CHG (chlorhexidine) bathing recommended?

Answer 21

For infection prevention in hospitalized clients.

Question 22

Describe perineal care.

Answer 22

Cleansing of genital and perianal areas from front to back to reduce infection risk.

Question 23

When assisting a dementia client with ADLs, what should the nurse prioritize?

Answer 23

Provide individualized support and respect for routine.

Question 24

Which clients need closer monitoring for foot care?

Answer 24

Diabetic clients (high infection risk).

Question 25

Nail care rule for diabetic clients?

Answer 25

Do not trim nails without provider order; file straight across.

Question 26

What should be used for facial shaving in clients on anticoagulants?

Answer 26

Electric razor.

Question 27

When should bed linens be changed?

Answer 27

When soiled or at least daily for immobile clients.

Question 28

What hygiene challenge is often an early sign of dementia?

Answer 28

Decline in personal hygiene habits.

Question 29

How does the hypodermis help thermoregulation?

Answer 29

Insulates and retains body heat.

Question 30

Two key infection-prevention strategies in care provision?

Answer 30

Hand hygiene and use of PPE.

Question 31

Which brain structure controls the sleep–wake cycle?

Answer 31

Hypothalamus and suprachiasmatic nucleus.

Question 32

What is the main hormone that induces sleep?

Answer 32

Melatonin (pineal gland).

Question 33

Stage 1 sleep is characterized by which brain waves?

Answer 33

Alpha and beta waves (lightest sleep).

Question 34

Stage 3 sleep helps the body how?

Answer 34

Repairs muscles and tissues; strengthens immune system.

Question 35

How long after sleep onset does REM typically begin?

Answer 35

Approximately 90 minutes.

Question 36

Which sleep stage involves dreaming?

Answer 36

Stage 4 (REM sleep).

Question 37

Older adults spend more time in which sleep stage?

Answer 37

Stage 2; less in deep Stage 3 sleep.

Question 38

How many hours of sleep are recommended for young adults?

Answer 38

7–9 hours per night.

Question 39

What effect does sleep deprivation have on nurses?

Answer 39

Decreased judgment and reaction time; increased error risk.

Question 40

What sleep-hygiene advice should a nurse give?

Answer 40

Avoid caffeine/alcohol 4–6 h before bed; keep room dark and cool.

Question 41

What is narcolepsy?

Answer 41

Chronic neurological disorder with sudden sleep episodes.

Question 42

What condition causes periodic breathing stops during sleep?

Answer 42

Obstructive sleep apnea (OSA).

Question 43

Which test diagnoses OSA?

Answer 43

Nocturnal polysomnography.

Question 44

Define hypersomnia.

Answer 44

Excessive daytime sleepiness despite adequate night sleep.

Question 45

What is restless leg syndrome (RLS)?

Answer 45

Uncontrollable urge to move legs during sleep.

Question 46

How does circadian rhythm differ from sleep-wake homeostasis?

Answer 46

Circadian = 24-h biological clock; Homeostasis = pressure to sleep after wake time.

Question 47

What lifestyle modification aids chronic insomnia?

Answer 47

Consistent sleep schedule and bedtime routine.

Question 48

Why should naps be short and before 3 PM?

Answer 48

Long/late naps disrupt night sleep cycles.

Question 49

What should clients do if they can’t sleep within 20 minutes?

Answer 49

Leave bedroom, relax elsewhere until sleepy.

Question 50

What activities should the bedroom be reserved for?

Answer 50

Sleep and sexual activity only.

Question 51

Postoperative pain management best practice?

Answer 51

Use multimodal approach (PCA + non-pharmacologic).

Question 52

Client with opioid PCA develops RR of 8 breaths/min—nurse action?

Answer 52

Stop infusion, stimulate client, notify provider immediately.

Question 53

Before bed bath for an immobile client, what should nurse assess?

Answer 53

Skin integrity and tolerance to movement.

Question 54

In perioperative period, oral care reduces risk of what?

Answer 54

Ventilator-associated pneumonia and infection spread.

Question 55

How do nurses prevent skin breakdown in bedridden clients?

Answer 55

Reposition q2 h, keep skin dry, use pressure-relief devices.

Question 56

Which stage of sleep is essential for memory consolidation?

Answer 56

REM sleep.

Question 57

Patient reports daytime fatigue and snoring—priority action?

Answer 57

Refer for sleep study (assess for OSA).

Question 58

Client with diabetes asks about foot soaking—nurse response?

Answer 58

Avoid soaking; inspect feet daily and keep dry.

Question 59

What should the nurse do before shaving a male client on warfarin?

Answer 59

Use electric razor to prevent nicks.

Question 60

Which intervention improves sleep for hospitalized clients?

Answer 60

Cluster care to minimize nighttime interruptions.