A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of ...

A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
 
  a. Administer prescribed sedatives or opioids at bedtime to promote sleep.
  b. Cluster nursing activities so that the patient has uninterrupted rest periods.
  c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
  d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.

Question 2

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
 
  a. Sleep disturbances
  b. Multiple tender points
  c. Cardiac palpitations and dizziness
  d. Multijoint pain with inflammation and swelling
  e. Widespread bilateral, burning musculoskeletal pain

Question 3

When reviewing the chart shown in the accompanying figure for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient?
 
  a. A
  b. B
  c. C
  d. D

Question 4

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma?
 
  a. Monitor for difficulty in breathing.
  b. Document the patient's oral intake.
  c. Check finger strength and movement.
  d. Apply capsaicin (Zostrix) cream to hands.

Question 5

After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider?
 
  a. Knee crepitation is noted with normal knee range of motion.
  b. Patient reports embarrassment about having Heberden's nodes.
  c. Patient's knee pain while golfing has increased over the last year.
  d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

Question 6

A 28-year-old with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?
 
  a. Crackles are heard in both lung bases.
  b. Red, scaly patches are noted on the arms.
  c. Hemoglobin level is 11.1g/dL and hematocrit is 35.
  d. Patient reports continued back pain after a week of etanercept therapy.